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CHARLES EDWARD FITZGERALD, M.D. 



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DUBLIN JOURNAL 



OF 



MEDICAL SCIENCE. 



EDITED BY 

SIR JOHN W. MOORE, MA., M.D., M.Ch. Duel., D.Sc. Oxon., 

PAST-PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF IRELAND, 

SENIOR PHYSICIAN TO THE MEATH HOSPITAL AND CODNTY DUBLIN INFIRMARY 

CONSULTING PHYSICIAN TO CORK-STREET FEVER HOSPITAL, 

EX-SCHOLAR AND DIPLOMATE IN STATE MEDICINE 

OF TRINITY COLLEGE, DUBLIN. . 

HONORARY PHYSICIAN IN ORDINARY TO H. M. THE KING IN IRELAKD ; 

and 

T. GILLMAN MOORHEAD, BA., M.D. Dubl., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF IRELAND, 

PHYSICIAN TO THE ROYAL CITY OF DUBLIN HOSPITAL, 

CONSULTING PHYSICIAN TO THE CLONSKEAGH FEVER HOSPITAL, 

DIPLOMATE IN STATE MEDICINE. 



VOL. CXLII. 

JULY TO DECEMBER, 1916. 



DUBLIN; 
PANNIN & COMPANY. Ltd.. GKAFTON-STREET 

LONDON: SIMPKIN, MARSHALL & CO. 

EDINBURGH: JAMES THIN. 

PARIS: HACHETTE & CO. 

iyi6. 



UOBLIN : TAINTED BY JOHN FALCONER, 53 CPPEE RACKVILLE- STREET. 




THE DUBLIN JOURNAL 



OP 



MEDICAL SCIENCE. 

JULY 1, 1916. 

PART I. 
OKTOTNAL COMMUNICATIONS 



Art. I. — Notes on Camp Jaundice. By T. Gillman 
MooRHEAD, M.D., Dubl. ; F.R.C.P.I. : Captain (Temp.). 
R.A.M.C, and G. D. Harding, M.B., Captain (Temp.), 
R.A.M.C. 

Epidemic jaundice has been extremely prevalent amongst 
the troops in the various theatres of war, but especialh' 
in the Mediterranean, and. although fortunately mild in 
character as far as mortality is concerned, has proved an 
important factor in depleting the units engaged in the 
field. 

The exact nature and causation of this jaundice has 
been a matter of much discussion and varied opinions, 
some inclining to the view that it does not differ in any 
way from ordinary catarrhal jaundice as met with at 
home, others regarding it as a mild form of Weil's disease, 
and still others looking on it as a disease sui generis, 
caused by a specific, but as yet unidentified, organism. 

During the past three months, while serving in the 
medical wards of a general hospital, we have had an 
opportunity of observing some sixty cases in all of jaundice 

VOL. CXLII. — NO. 535, THIRD SERIES. A 



2 Notes on Gamp Jaundice. 

that have been under ovir treatment in that institution. 
Of these cases, fifty seem to have belonged definitely to 
the type that has been so abundant, and constitute a 
series on which the following notes are based. 

Before proceeding to describe the characteristics of these 
cases, it may be as well to point out that, as far as this 
hospital is concerned, the disease seems for the time being 
to have ceased to exist, as, during the past few weeks, no 
cases have been admitted, and no cases have developed 
within the hospital itself. We may add that, as far as we 
can judge, the cases we have seen have been of a milder 
type than those met with elsewhere, though we have no 
reason to believe that they otherwise differ in nature from 
the cases treated at other hospitals m the Mediter- 
ranean area. Within the limits of age of the men com- 
l^rising our troops no age appears to have been exempt ; 
some of our patients being under twenty and others over 
fifty years of age. The average age, as might be expected, 
was about twenty-eight. 

Most of the cases came from local camps, but a few 

came direct from and had either acquired th? 

disease there or on board the boat on their way thence 

to . None of the local camps seemed to be 

immune, though, OAving to our situation, a greater number 
of cases was admitted from one of the camps than from 
most of the others put togethei". A iew of the cases 
developed theii- first sym])t()ms shortly after arrival in the 
East, })ut by far the greater number had been away from 
b]ngland for some months before the jaundice appeared, 
This is a point of some importance as regards tetiology. 

The mode of onset was very similar in all the cases. 
As a rule, the first symptoms noted were loss of appetite and 
a general feeling of not being well. These were followed by 
nausea and in most cases by vomiting. Headache, 
especially retro-orbital pain, giddiness, pains in the 
stomach, and occasionally diarrhcea were next complained 
of, and, in addition, ])aiMs in the bones and back. The 
jaundice jirst ai)|)eared. on an average, four and a half 



By ('aptatxs T. (1. AIookhead and G. D. TTAT^nTNo. 8 

days after the beginning of the illness, and in many of our 
cases was present at the time of admission. 

At first, there is slight tinging of the sclerotic, followed 
liy general discolouration of the skin, the appearance of 
clay-coloured stools, bilious urine, and all the usual 
phenomena that accompany early obstructive jaundice. 
By the time these symptoms had developed, the vomiting, 
and frequently also the nausea, had ceased, and constipa- 
tion was present. 

Analysis of the symptoms and signs presented by the 
patients at the time of admission and during the course of 
their stay in hospital revealed the following phenomena in 
addition to the jaundice : — 

1 . Temperature. — ^This was raised above normal in 
twelve out of the fifty cases, the highest point reached being 
103° F., which level was reached in four cases. In no case 
did the temperature remain above normal for longer than 
five days. In the remaining thirty-eight cases the course 
in hospital was Ciuite afebrile, but it is, of course, impossible 
to say whether fever had been present before admission 
or not. From the other symptoms complained of, and 
from the records by other observers, it seems likely that 
the illness is usually characterised by a short febrile period 
at the commencement. 

2. Pulse. — During the febrile period, the pulse ranged 
between 80 and 90 per minute, but as soon as the pain had 
subsided the pulse came down and remained abnormally 
slow as long as the jaundice persisted. As soon as the 
patients were allowed up, it again became rather rapid, 
but did not show any other abnormality. 

3. Liver. — In thirty-one out of the fifty cases the liver 
was definitely enlarged, and was very tender on pressure. 
The enlargement was often extremely pronounced, and in 
a few cases extended downwards almost as far as the 
umbilicus. In most cases, however, it did not exceed 
two or three finger-breadths below the costal margin. As 
a rale no pain was complained of unless pressure was made 
over the organ, 



4 Notes on Camp Jaundice. 

4. Spleen. — Enlargement of the spleen is regarded as 
one of the characteristic features of Weil's disease, and 
it is stated that in a majority of the cases of epidemic 
jaundice, met with elsewhere, enlargement has been present. 
In only seven of our cases, however, could any enlarge- 
ment be detected. In these seven the enlargement was 
quite distinct, and palpation caused considerable pain. In 
the other forty-three cases no enlargement could be made 
out either by percussion or by palpation. No difference 
in the other clinical phenomena was observed between 
those cases in which the spleen was enlarged and those in 
which it was not. 

5. Urine. — Nothing of special note was made out in the 
routine examination of the urine. Bile pigments were 
invariably present, but only in a few cases was there even 
a trace of albumen, and in no case was blood present or 
were renal casts found. In ten cases catheter specimens 
of urine were drawn and cultures made, but in each case 
the culture proved sterile. 

6. Mouth. — ^The tongue was generally furred and flabby, 
but no special soreness of the mouth and throat, such as 
has been referred to by other observers, was present in our 
cases. 

7. Blood examinations were made in twenty of the cases 
and gave the following results : — 

(a) A moderate leucocytosis was present, the average 
of a series of counts giving 11,018 white blood corpuscles 
per c.mm. The highest count obtained was 18,600 per 
c.mm. in a febrile case, and the lowest was 7,500. 

{h) Differential counts of the white cells gave the follow- 
ing average results : — 

Neutrophiles - - 53.4 per cent. 

Lymphocytes - - 40.7 „ 

Large mononuclear cells - 4.7 ,, 
Basophiles - - .0 ,, 

Eosinophiles - - .0 ,, 

From these figures it will be seen that there is a relative 
preponderance of the lymphocytes as compared with 



By Captains T. G. Moorhead and G. D. Harding. 5 

normal. No exception to this relative lymphocytosis was 
found in any of the cases examined. 

(c) Cultures were made by Lieutenant Willmore from 
the blood in seven cases only, and in each of these the 
culture fluid remained sterile. 

(d) In a good many of the cases agglutination tests were 
carried out with the B. typhosus and the paratyphoid 
A. and B. bacilli. With the exception of one case — not 
included in the series — that developed in a few days 
definite symptoms of paratyphoid fever, all the tests were 
negative as far as the paratyphoid group was concerned. 
As regards the B. typhosus, partial agglutination was 
obtained in several of the cases, but as all the patients 
had been inoculated against typhoid, and as many other 
non -jaundice cases gave a similar agglutination, this 
result may be discounted. 

As regards the duration of the illness, it was found that 
the jaundice almost invariably began to diminish in about 
a week after its first appearance, and that it had practically 
completely disappeared after a fortnight. Most of the 
patients were able to leave hospital within a month after 
admission. In three out of the fifty cases, however, the 
duration of the illness was much more prolonged, one case 
remaining jaundiced for five weeks. In two cases relapses 
occurred after a fortnight of nearly normal health. 

As it is important to determine whether this form of 
jaundice is in any way related to other diseases, special 
inquiry was made on this point, and it was found that in 
no case had the patient previously suffered from enteric 
fever or malaria. In seven cases there was a definite 
history of previous dysentery, but these cases did not 
differ from the others. One patient was convalescent 
from pneumonia when the jaundice set in ; three cases 
suffered concurrently from trench-feet and from the 
jaundice ; one patient had had an attack of influenza a 
month previously ; and in two cases the patients were 
recovering from operations for acute appendicitis when 
the illness fii'st manifested itself. In no case was there 



6 Notes u)i Camp Jaiutdice. 

any history of having been in contact with other jaundice 
cases. 

Complications and Sequelce. — Practically no complica- 
tions were noted, with the exception of one case, in which 
a zone of herpes appeared round the thorax in the febrile 
stage ; in two other cases well-marked labial herpes was 
present. One case developed rather severe nervous 
symptoms quite early, and at the same time had acute 
dilatation of the heart. After a few days' active delirium, 
however, he began to improve, and made a good recovery. 

During convalescence special attention was paid to the 
condition of the heart and blood pressure, as many 
observers are of opinion that the heart suffers severely 
in the disease. Our experience, however, only partly 
bears out this view. Undoubtedly the pulse is faster than 
normal when the patient first begins to get about' during 
convalescence, and in a few cases some cardiac dilatation 
can be detected. Further, the patients are considerably 
debilitated in some cases, and require a long period of rest 
before resuming active work ; but, on the other hand, 
many patients felt quite well during their entire stay in 
hos})ital, even when the jaundice was present, and, as soon 
as they were allowed out, expressed themselves as feeling 
quite strong and restored to normal health. 

The blood pressure A\as taken in many of the cases, 
more especially during the period of recovery, and was 
found to be rather low — namely, on an average, 105 mm. 
Hg. Pressure estimations, however, made on other 
patients, suffering from minor ailments, gave a similar 
low average reading, and in consequence very little 
importance attaches, in oui' opinion, to the results in the 
jaundice cases. Our reason for laying stress on the condi- 
tion of the vasculai- system is the fact that, in cases 
admitted from Chatby, a suburb of Alexandria, to another 
military hospital during the summer and autumn of last 
year, maiked cardiac dilatation was a striking clinical 
feature ; and further, in a few fatal cases that occurred 
here and tiicre thioughout the hospitals, cardiac degenera- 



By Captaiks T. G. M()0I{HEAD and G. D. PTarding. 7 

tion Avas generally found. Our observations on patients 
admitted to this hospital for dysentery, enteric fever and 
other diseases leads us, however, to think that in troops 
who have been subjected to hardship and heavy physical 
work, almost any illness, if severe enough, will affect the 
myocardium. Our cases of jaundice, as already stated, 
were of a mild nature, and in consequence the heart 
suffered very little. Doubtless, if the illness had been 
more severe, the heart would have become dilated, but, 
as it is, we cannot accept pronounced cardiac dilatation 
as one of the essential features of epidemic or camp 
jaundice. 

There were no fatalities in our cases. 

Treatment. — The treatment adopted was of the simplest. 
Each man was kept in bed till the jaundice had disappeared 
and usually for a few days subsequently. At first they 
were kept on liquid diet, and this was gradually increased 
as the tongue cleared and the symptoms improved. 

Each case on admission was given a dose of calomel, 
followed next morning by magnesium sulphate. Saline 
aperients were subsequently administered as required. 
During the first ten days a mixture containing sodium 
salicylate, sodium citrate, and sodium benzoate was also 
administered as a routine ; later on, tonics of the Easton's 
syrup type were ordered. 

The causation of this form of jaundice still remains 
unsolved. At first we were inclined to regard it as 
identical with ordinary catarrhal jaundice, and to regard 
it as being caused by intestinal catarrh set up by the 
general change of food and conditions to which the soldier 
is subjected on coming abroad. Further experience, 
however, led us to believe that it differs from ordinary 
catarrhal jaundice, the points in favour of this being — ■ 
(1) the initial febrile period ; (2) the fact that the enlarge- 
ment and tenderness of the liver are much more pronounced 
than in catarrhal jaundice ; (3) fairly frequent occurrence 
of splenic enlargement ; (4) the distinct lymphocytosis ; 
(5) the fact that most patients do not develop the disease 



8 Notes on Camp Jaundice. 

soon after arrival from home, when, presumably, they 
would be more liable to be affected by the change. On 
the contrary, it usually appears after residence for some 
considerable time in camp. And this fact seems to point 
strongly to some bacterial source originating, doubtless, in 
insanitary conditions. The way to tackle the problem 
seems to us to lie more in improving, as far as possible, the 
sanitary state of all camps than in anything else. From 
what we have heard and seen, flies do not seem to play any 
important part in disseminating the cause of the disease, 
as during the last few months flies have been very scarce, 
and we are informed that the disease was not more frequent 
in those parts of where flies were most abundant. 

Although, doubtless, there is a definite bacterial cause 
for the disease, predisposing factors should not be lost 
sight of, and in this connection the importance of diet and 
of exposure to cold must be remembered. The initial 
symptoms point strongly to an acute gastro-duodenitis as 
the primaiy pathological lesion. This is almost certainly 
followed by a catarrh of the common bile duct, which 
probably extends upwards and involves many of the 
smaller bile channels within the liver. Whether the con- 
dition should be regarded as identical with Weil's disease 
or not is more a question of terminology than anything else, 
as nothing definite is known concerning the bacteriology 
of Weil's disease. Sandwith describes this disease as met 
with in Egypt as being an acute infectious disease some- 
times becoming epidemic during the summer months and 
characterised by fever, jaundice, enlarged liver and spleen, 
nephritis and some nervous symptoms. 

And Kartulis, in discussing its causation, lays stress on 
two factors — namely, («) the consumption of spoiled or 
fouled food and the drinking of stagnant water, and 
(h) living in unhealthy localities with defective sanitation. 
Both these causes, but especially the latter, arc almost 
of necessity operative at times in our camps and trenches, 
and the realisation of their importance should add force to 
the efforts that are constantly being made to overcome them. 



The Metabolistu of Scuih' Decay. 



Art. II. — The Metabolism of Senile Decay. By Edwin 

VVOOTON. 

The accepted physiological view of a human organism's 
life history is that from the moment of cellular conjugation 
it consists in a sequence of activities necessitated by 
inhering laws ; a sequence which — if not broken fatally 
by some adventitious mean — must end in death from 
senile decay ; in other words, from exhaustion of those 
metabolic powers which are essential for life. It is well 
to mentally masticate this teaching. It affirms that just 
as the potentialities of the two parent cells make for a 
cycle of changes that bring a babe into being, so the parts 
and organs of that babe carry their further history by an 
inhering and unalterable constitution of each cell ; that 
there is nothing of chance or accident in age decay ; that 
it is not due to any error — active or passively imported — 
but is as sure, as natural, and as inevitable as the develop- 
ment of the impregnated ovum ; that it is the proper 
termination of powers whose limitations were fixed from 
the beginning, and to which nothing can be added. 

While such views are held generally, save by those 
students who claim an esoteric knowledge foreign to 
Western physical science, there are many Avho regard the 
ordinary life period of eighty or thereby as unnecessarily 
brief. They urge that by paying stricter attention to 
health laws there can be a reasonable extension of life 
duration ; but essentially their views are identical with 
those stated, in that they see life as a cycle, and their 
utmost hope does not extend beyond enabling the organism 
to live it out to its delimited point of activity. 

I am not coming forward in this article A\ith the an- 
nouncement of an " elixir vitce " ; but I shall strive to 
show that Ave have reasonable ground for doubting the 
accuracy of the accepted view ; reasonable ground for 
regarding the mischief termed " senile decay "" as brought 
about by something quite foreign to natal predestined 



10 The Metabolism of Senile Decay. 

cellular damnation, as something, indeed, largely fortui- 
tous. If I succeed in this effort, life prolongation vyill 
become as practical a problem as the cure of cancer or 
of tuberculosis. 

The differences in physical character betAveen the body 
of an aged and that of a young adult are structural, 
chemical, and functional. Metchnikoff has said with 
truth : — " On resume la senilite par un seul mot : atrophied 
The old grow shorter ; partly this is due to an acquired 
bad carriage, but always it is owing chiefly to the thinning 
and ossification of the invertebral cartilages. The skeleton 
becomes altered as age advances ; much of the internal 
spongy texture is removed, and the process is often co- 
incident with calcification of soft parts. Muscular fibres 
lessen in number and in size. The digestive glands of 
the stomach atrophy. An increase in the connective 
tissue between the pulmonary air cells obtains, so pressing 
on the breathing space and stiffening the lung. Arteries 
undergo the degenerative changes bracketed as sclerosis. 
In brief, the entire organism suffers from a substitution 
of inferior grade tissue for that of a higher type. An 
inversive process has been at work. The child was 
brought to the birth and brought from birth to adult 
vigour by progressive specialisation of tissues ; the 
vigorous adult in making for senile decay undergoes de- 
specialisation. Histologically, death from old age is the 
victory of the connective over specialised tissues. 

All such structural changes have their chemical factors ; 
a structural alteration is chemical action made visible ; 
and the final result — organic functional failure — is also 
largely chemical. 

A child in utero is an example of almost perfect meta- 
bolism and oytoniorphosis. Its body can dispose of all 
(he niitrimeiit, save a negligible fraction, with which it is 
sii|)j)Ue(l. Hertwig, of Munich, has estimated the volume 
of the human fertilised ox um as the two hundred and 
fiftieth part of a cubic millimetre, and that of the child 
at l)ii'th as from three to tour million cubic millimetres — 



By Edwin Wooton. 11 

that is, the growth has been one thousand million times 
the original size. Assuming an individual to weigh seven 
pounds at birth and one hundred and forty pounds at 
twenty years, his increase in weight will be merely nineteen 
multiples. The rate of growth may be said to decrease 
almost from the date of conception to maturity. 

At birth the child has an enormous avenue for disposing 
of ingested mineral salts. Its demand for proteins and 
sugar makes over-feeding a rarity. It may. be afhrmed 
with confidence that when more food is taken than can 
be dealt with by the digestive organs it is thrown up or 
cast out by the bowels. It does not undergo absorption 
and then work mischief. The child uses up in proportion 
to its size far more calories than an adult. It does this 
because it loses heat more rapidly than the adult ; not. 
however, as is often erroneously said, by reason of smaller 
surface, but from smaller bulk. A piece of thin iron one 
foot square will lose heat more rapidly than a cubic inch 
of iron heated to the same point. It is mass that counts 
in the retention of heat ; surface that counts in its loss. 

For each kilogramme of weight in the babe the heat 
production is about one hundred calories, as against 
thirty for the adiilt. The normal increase in weight of an 
infant corresponds to retention of from 12 to 20 per cent, 
of the calorie equivalent of the total metabolism. The 
retention of protein may be set down as from 25 to 40 
per cent, of the protein ingested. 

Growth depends absolutely upon the excess of food 
beyond the needs for heat production. 

When we follow up the figures they are startling. A 
\'Oung boy engaged in active play demands a metabolism 
of about forty calories per kilometre per diem. The 
demand may^ even rise to a hundred. The diet of such a 
boy has to satisfy basal w ear and tear, growth, heat pro- 
duction, and the demands made by exercise. There is 
little difference between the food quantity needed by him 
at the age of ten or tweh e and that of an adult outdoor 
labourer. 



12 Tlie Metaholism of Senile Decay. 

How is it that the child disposes of the waste inseparable 
from such metabolic activity ? Because in proportion to 
the child's body size its liver is far larger than that of the 
adult. Of all organs concerned with waste removal the 
liver is the most important. The babe's liver weighs at 
birth about 4.9 oz. The weight of an adult's liver is, 
variably, near sixty ounces. The proportion between the 
two is very nearly as 1 to 13. The weight of a babe's 
body may be set down as seven pounds ; that of a well- 
fleshed adult as one hundred and eighty-two pounds ; the 
proportion is ] to 26. The proportion of the adult's liver 
weight to body weight is about 1 to 49 ; that of the babe's 
liver weight to body weight is, roughly, 1 to 22. 

Even if one discounts these figures largely the difference 
Avill still be striking. Under no conceivable condition 
compatible with good health has an adult more than two- 
thirds of the proportionate liver weight possessed at birth. 

Although by the age of ten or twelve the proportion 
obtaining at birth has been lessened, there is an immense 
balance still in the child's favour. 

A healthy child never under any environment acquires 
gout. The nearest approaches to this are the renal and 
urinary deposits of uric acid seen sometimes in those of 
gouty descent. The case is not one ot immunity. There 
is no law involved. That which obtains is a comparative 
ability to dispose healthfully of all nitrogenous tissue 
waste ; an ability so marked that gout as gout does not 
occur in childhood. 

Relatively to its body mass a child passes more urea 
than an adult. Uhle states that children between the 
ages of three and six pass one gramme per kilo, per diem. 
Quantities and proportions vary, but there is always an 
excess per kilo, over the adult output. 

The child's behaviour towards sarcolactic acid is equally 
satisfactory under normal conditions, but is very different 
when these are upset. Saicolactic acid is piodiiced chiefly 
by the muscular tissue. Any sudden deprivation of heat 
may block the outlet of the acid, with muscular rheu- 
matism for result. Latcj-, as the retained acid begins to 



By Edwin Wooton. 13 

flood the system in quantity too large for reduction to 
carbon dioxide and water, it initiates valvidar and joint 
impairments. 

During the later months of pregnancy the fibrin of the 
maternal blood is greatly increased. Fibrin is a calcium 
compound of fibrinogen. Its increase is the mean whereby 
the foetus is supplied with calcium, the demand for which 
is obvious. This is the earliest example of the tact that 
in the human body fibrin is the chief lime carrier ; it is 
the main healthy vehicle for the mineral. Now, in ad- 
vanced life fibrin decreases ; and it is at this period that 
chronic joint deposits of calcareous material are most 
frequent. It is at this period also that the oxygen intake 
is at its lowest, and such lessening must result in defective 
destruction of sarcolactic acid. This acid has an affinity 
for calcium, seizing on it greedily ; and calcium has a 
marked affinity for albuminoid tissues. We know the 
readiness with which pathological structures and degene 
rate cells undergo calcification. From such facts we are 
not to conclude that the case is simple ; that it starts by 
sarcolactic acid attracting the calcium, and so lessening 
fibrin, and then proceeds by depositing its burden in 
weakling cellular structures. Doubtless, some such process 
plays its part, but there is lessened fibrinogen even when 
" rheumatic '•' changes are absent. It is more than likely 
that the rearranged metabolism has a far greater com- 
plexity. However that may be, we know the starting 
point of the mischief — undestroyed sarcolactic acid ; we 
knoAv its ending — calcareous metastasis. 

We have no reason whatever for supposing that in any 
part of this aberrant metabolism inhering laws are at 
work. In the adult, as in the child, the starting cause is 
the fortuitous acquirement of a chill. " No chill, no rheu- 
matism," is a medical canon ; and bio-chemistry points to 
the impossibility of calcareous metastasis while the acid 
is undergoing normal destruction. From other and allied 
causes various parts of the aged body mav be more ready 
for receipt of such injury than in the young adult ; but 



14 Tlte Metaholifini of Smile Decay. 

the mean — the retention of the acid — is accidental, and 
without this mean the pathological changes could not take 
place. 

A human being may be said to start life M'ith an excess 
poAver of fitting waste for removal. There comes the de- 
clension, but before this is the point of equilibrium. 
Doubtless, this is variable within limits. Roughly, it may 
be set down as occurring between the twenty-first and 
twenty-fifth years. The body is now in its highest physio 
logical state for the needs of existence. All the ossific 
changes essential for strength are near to or have arrived 
at completion. As yet no cellular deterioration has mani- 
fested itself. Equilibrium is but brief. It is from now, 
Avhen the declining power fails to meet the demand, that 
we see the incidence of all those miscliiefs that in their 
sequence and collectively result in decrepitude. 

There can be no doubt that metabolism becomes imper- 
fect before the meridian of strength is reached. Always 
its first indication is in the skin. Not merely the epidermis 
but the corium is coarsened ; the inferior is being substi- 
tuted for the superior tissue. The initial impairments 
spread to the muscles ; they get less speedy in responding 
to stimuli. A little later, exercise develops muscle not 
by giving any increase in number of cells, but by cellular 
enlargement. There is little need to pursue details ; we 
all know them too well, with their innumerable variants, 
yet of type unv arying : cellular deterioration within blood 
vessels, fatty degeneration, hyperplasia of connective 
1 issues, the de-specialisatiou of function, organs becoming 
])rogiessively less active, each acting on all, and all on 
each, until the point of functional cessation is reached. 

Despite many impairments of cellular stnicture a man 
may keep what is teimed " health "" — that is, he may so 
conserve his vigour that its gradual declension will be 
almost imperceptible. The speed is slowed, but the 
traveller is making for the same teiminus as the one who 
is health-bi'okeu. in oidinary life its tenure is influenced 
f)y observance or negUMl of rules, dietetic and hygienic, 



By Kdwin Wooton. 15 

both general, and specialised for the individual. It is 
always easy to make an estimate of the body's food needs ; 
always easy to arrive at a judgment as to expenditure — 
muscular, cerebral, or otherwise — that must be met ; but 
when we have formulated a diet scheme that offends in 
no detail ; when every health law is obeyed we see our 
success is miserably small. We can lead to a healthy old 
age, a healthy senility, a healthy mockery of health, a 
thing that is puffed out like a taper. 

Why the failure ? 

We are face to face with the prol)lem of waste ; with 
waste — exogenous and endogenous. 

Were we to say in brutal simple English : — We poison 
the body by bad food, and excess of food ; and always 
the body poisons itself — and, if we want to keep youth 
we must take in all the pure air we can, and keej) the 
circulation of blood as active as we can, and maintain to 
our utmost power the activit}- of every excretory organ — 
our words would cover not only what we know, but what 
at any time we may know ; would cover all possible 
knowledge ; for it is the satisfaction of the needs implied 
in these words that renders metabolism in early life 
perfect. 

Organic chemistry, like many other things that pas-^ 
for verities, is alloyed with a considerable percentage of 
make-believe. That is still more the case with the division 
known as bio-chemistry. One is inclined to think of bio- 
chemical analyses as on a par with inorganic. The latter 
are constant and exhausti\ e. leaving nothing for opinion. 
Bio-chemical lesearches have an immensely wider field, 
far more unstable and complex compounds, and the 
relationship of these to other compounds is more frequently 
a matter of probability than certitude. It is because 
of these and allied obtaining facts that bio-chemical 
authorities differ so markedly in their teaching. It would 
be grossly unfair to call it guess-work, and equally foolish 
to think any detail of their teaching a finality. It deals 
chiefly with a series of what I may term " Oids "' — things 



16 Tlir Mrfaholifiin of Senile Deemj. 

that are near to the truth, and may contain more or less 
of absohite truth, and that make for the truth. 

The body is a laboratory. But again one is apt to think 
of it as of a something where definite products pass through 
a plain sequence of changes in such way that the series of 
equations could be set out in straight lines. Chemical 
philosophy is showing the certitude of something very 
different. The simplest protoplasm is complex ; the 
simplest organised body yet more so ; and in the case of 
man the complexity is beyond description. The case is 
not one of an N number of principles undergoing an N 
number of reactions until an K number of ultimates have 
been formed. One might draw the symbols of such a 
scheme on the wall surface of a room. The case is rather 
one where by-products initiate further reactions, and by- 
products of these yet others, and these link up here, there, 
and everywhere. The crudest attempt to giv e the complete 
symbols of human bio-chemistry would need to be done 
in three dimensions, not two. 

Let us thank Heaven that the greater contains the less ; 
that if we have the makros, we need not trouble about the 
mikros ; that kindly old Nature sees to these things. 
Such consideratiotis enalile us to value rightly the teaching 
of to-day with regard to katabolic chemistry. 

Although for convenience sake the causes of metabolic 
impairment are sometimes classified as endogenous and 
exogenous, they are all of the former character proxi- 
mately. 

Their essential character is defective oxygenation. 

There are two chief groups of nitrogenous tissue waste 
products; the one grouj) is nitrogenous, like its source; 
the other is not, and is exemplified by sarcolactic acid 
(( !3H..,0:j)2 and carbon dioxide. The nitrogenous pro- 
ducts, by a series of hydrolyses and subsequent oxygena- 
tion, ultimately leave the body as urea, uric acid, and 
urates ; possibly also as certain sweat acids. 

Nuclease, an intracellular enzyme, breaks down micleo- 
protcin into protein, phosphoric acid, adenin, guanin, 
hypoxanthin, and xanthiii. That may be called stage one. 



By Edwin Wooton. 17 

The hypoxanthin is now changed into xanthin, and the 
gnanin into xanthin. 

That may be called stage tAvo. 

The xanthin becomes uric acid ; that is stage three. 
Some part of the uric acid is made into urea ; another part 
takes up sodium, and circulates as the quadriurate, and 
the remainder is excreted as free acid. 

That is somewhere round about the truth. 

If such reductions are interrupted what happens ? 

Always one thing, no matter what else results — cellular 
impairment. As a consequence, always the lowering of 
functional power on the part of vital organs, w. hich, to the 
physiologist, means that every cell of the body is progres- 
sively impaired, for each depends on all, and all depend 
on each — so far as vital stiiictures are concerned. 

If there is faulty endogenous reduction, the exogenous 
cannot be rightly carried out. If the enzymes fail with 
cellular material jjroper to the body, how can it be thought 
that they will succeed with a heterogeneous mass of foreign 
organic stuff thrown into the circulating media ? 

Metabolism there is — of a kind ; but each meal adds a 
new and impossible task to the labours of the reducing 
agents. 

Apart from this death-cycle, the result may be any one 
of many. Thus, the quadriurate may become the biurate, 
and occasion gout. Uric acid may be deposited in the 
kidney, and cause nephritis. Stone or gravel may result. 
The organism may become so non-resistant in some part 
as to yield to invading microbes. Anything may come 
about ; and, if the agents for destniction do not suffice, 
the body wall destroy itself. Metchnikoff's researches 
have proved this. He has shown that autophagy of the 
body by its leucocytes, and its autolysis by chemical 
action are facts, not theories. One need not go with him 
all the way as to the influence of a sluggish large intestine. 
That is more theoretical than otherwise. The power of 
absorbed intestinal products to bring about the cell 
weakening essential for such mischief is a matter of 

B 



18 The Mctahnlisw of Smile Deeny. 

opinion ; the power of iinremoved nitrogenous Avaste to 
effect the weakening i.s a matter of certainty. We never 
see lethal results from chronic fsecal septicism in youth. 
Sluggish bowels may injure in early life, but they do not 
bring about cellular changes of senile character. Meta- 
bolism becomes impaired to the danger point when, and 
not until, oxygenation of intracellular waste is defective. 

Very similar considerations apply to exogenous sub- 
stances. Excess of food, and especially of certain kinds — 
those purin laden — has for results an increased production 
of uric acid, and its defective ox3^genation ; injury of the 
" gout "" type, and the cellular deteriorative type ; and 
if to such fortuitous agency there is added comparative 
inaction of the muscles — ^that plump and conifortal)le 
inertia of middle life — we have all-sufficing conditions for 
a rapid poisoning of the system. 

No perfection of metabolism can withstand these, but 
necessitated they are not. Ko perfection of metabolism 
in the young athlete will shield him from the consequences 
of a neglected rubbing down when heated. It is the very 
perfection of function that gives " accident " such power. 
The trained muscle has been lavish in its work ; its waste 
is being discharged into rapidly circulating media ; the 
blood is being sent generously to the surface that the 
temjjerature may be normally regulated ; and then — he 
sits on the damp grass ! 

I have spoken of the makros and mikros in metaliolism. 
That same truth of the greater including the lesser applies 
to oui' poor little efforts at betterment. Conceivably, of 
course, our knowledge may advance to such an extent 
that we shall be able to control the output of xanthin, or 
some other chemical subtlety just as surely as we can use 
an aperient or diuretic ; ))ut that "Tipperary"' is a long way 
off. What we can do now is to go on the safe principle 
of thiashing the school, while trusting that the real 
offenders will feci it most, 

i'rom empiricism has come science ; and where science fails 
the old empiricism must again rule. There is no help for it. 



By Edwtx Wootox. 19 

There are some quite eoninionplace facts w liicli should 
give those of us pause who iucline to the \ie\v that senile 
decay is a thing unpreventable. One is that the processes 
of senility can be accelerated by ordinary means, ft is 
easy to almost destroy gastric, hepatic, or renal function. 
We daily see the body so injured. This is incompatible 
with fixed cyclic activity being true. On the other hand, 
right measures equally simple make for the more perfect 
performance of function. Hence the probability that our 
failure to stave off senile decay indefinitely is not because 
of inhering law, but because our stage of advance is not 
sufficiently forward. And, if we look at the pharmacology^ 
of the early nineteenth century, and compare it with that 
of to-day, we shall not be unduly optimistic in judging 
that the struggle is going in our favour. 

It must be kept in mind that humanity is hypnotised 
from its cradle into the belief that death is a certainty, 
not an accident. 

From this general habit of thought it has followed that 
few sustained efforts are made to fight defective meta- 
bolism from its incidence. The least likely to struggle 
are conservative physiologists — which is, perhaps, rather 
comforting than otherwise. The most likely to struggle 
are the enthusiastic but nerve-tr\dng people who kno^- 
no more of physiology than of the other side of the moon, 
but who live on oats, and break the ice before having a 
dip, and do other things equally silly. Genuine researcli 
and effort by the competent is \ ery rare. They do obtain, 
doubtless, and the results have been of value. But again 
there have been difficulties. Some of the chief workers 
have been men of advanced years, and these have experi- 
mented chiefly on themselves. The body of a man in 
later life does not exemplify the problem, it presents 
another of equal importance, but distinct from that under 
consideration. 

Let me here summarise the chief facts 1 have striven to 
elucidate : — 



20 Thr Metabolism of Senile Deeny. 

Senile decay is auto-failure ; it connotes metabolic im- 
pairment, and consequent poisoning. 

The poisoning works by the substitution of inferior 
grade for specialised tissues. 

There are two chief groups of poisons, the nitrogenous 
and the non -nitrogenous. 

The former gives rise to cellular deterioration ; the 
sarcolactic acid of the latter to calcification of soft parts 
and calcareous deposits. 

The. non-nitrogenous impairment may occur in child- 
hood, but is then modified because of the more j)erfect 
reception of oxygen, and the comparative cellular integrity 
due to greater liver power. 

These poisons are physiological, bio-chemical stages in 
the using up of endogenous or exogenous substances. 

Normally, the nitrogenous undergo hydrolysis and 
oxygenation, becoming uric acid, urea, and sodium- 
quadriurate. Normally, the non-nitrogenous poison 
(sarcolactic acid) is made into water and carbon dioxide. 

The liver is the chief waste-reducing organ of the body. 

In the child its proportionate size is larger than in the 
adult. 

Degeneration begins from the point where the normal 
organic power of poison reduction is unequal to the excess 
supply of material. 

That supply is largely augmented by exogenous material, 
more especially when purin-bearing. 

Senile decay is not due to any inhering limitation of 
cellular vitality. 

It is due to disproportion between organic parts. 

These facts bring forward the question : — Can we with 
the resources at command so raise the potential of re- 
ducing and excretory functions that they shall meet the 
demand made upon them. And as this is a subject not 
very fit for discussion at the fag end of a lirief article, 
I postpone its consideration. 

If, as a physiologist, 1 have seemed to trespass on the 
field open to the praclitiojiei- only, I crave pardon. At 



Clinical Report of the Rotunda Hospital. 21 

least I can make some amends by dii'ecting attention to the 
fact that in the coming time much of the domain hitherto 
roamed by the physiologist alone will be thrown wide to 
the practitioner in his daily work ; for, if the things that 
I have said are only approximately true, the day will 
arrive when the prevention of senile decay will be a 
commonplace and successful task. 



A.RT. III. — Clinical Report of the Rotunda Hospital for 
One Year, November 1st, 1914, to October 3lst, 1915. » 
By the Acting Masters, namely, SiR William J. Smyly, 
M.D., F.R.C.P.I. ; Richard D. Purefoy, M.D., 
F.R.C.S.I. ; and E. Hastings Tweedy, F.R.C.P.I. 

Introductory. 

The terrible war through which we are passing has greatly 
influenced the routine work of this Hospital during the 
year dealt with in our Report. The response to the Call 
to the Colours amongst the Professional Classes in Ireland 
has been as great, perhaps, as in any other part of the 
United Kingdom, and the Medical Profession has been 
conspicuous in this respect ; but nowhere has that 
call met with such a general response as it has done 
in the Rotunda Hospital. Dr. Henry Jellett, who had 
been re-appointed Master in November, 1914, resigned his 
position the following month to serve his Country in 
Belgium, and the Governors, being unable under the terms 
of their Charter to make a new appointment until the 
following November, invited the three surviving Past 
Masters to undertake the working of the Hospital for the 
remainder of the year. We gladly complied with their 
request, but have encountered unusual difficulties in the 
working of the Institution, because during the year we 
lost the services not only of both Assistant Masters — 
Dr. Crichton, who joined the R.A.M.C, and Dr. 

'^ Head before the .Section of Obstetrics in the Royal Aciidemy of 
Medicine in Ireland ou Friday, IVIay 19, 1916. 



22 Clinical Report of the Rotunda Hospital. 

Tottenham, who joined the Naval Medical Sei-vice — but 
also, for similar reasons, of one of our Clinical Clerks. 

The j)ost-graduate class, formed of Foreign and Colo- 
nial students, has almost entirely disappeared, and 
verj' few undergraduates attended. Our nursing sisters 
one after another obtained army appointments, and even 
the supply of probationer nurses fell off. In this connec- 
tion it is curious to note how many women living in 
England or Scotland who had entered for their course 
cancelled their engagements because of the submarine 
menace ; and, perhaps, in this they were not greatly to 
blame, for we have at present in our Hospital one nurse 
who went down in the Lnsitania, and who, when rescued, 
found that she had lost her husband and child. 

There Avere 1,760 deliveries in the External Department 
of the Hosi)ital, and 2,070 in the Intern Department. 
These figures show a considerable falling off in the former 
and a slight increase in the latter as compared with last 
year's Report. 

Extern Maternity. 
Tablk No. I. — Nature and Number of Cases Treated. 



Total Number of Labours - 1 


,760 


Operations' — • 




Abortions and Miscarriages 


166 


Version . . - 


10 


Hydramnios 


3 


Forceps • 


18 






Manual removal - 


19 


Presentations- 








Persistent occipito-iosterior 


14 


Children stillborn - 


88 


Face 


.") 


(Fresh, 75 ; macerated, 13) 




Breech 


58 






Brow 


1 






Transverse 


10 


Infantile Conditions — 




Twins 


20 


Spina bifida 


2 


Prolapse of cord 


9 


Anenccphalus 


2 


Placenta prpcvia 


() 


Hydrocephalus - 


2 


Accidental hajmorrhaj^'e 


4 


Mortality 


4 


Post j.arfum hsemorrhaj^c - 


21 






Lacerations of perineum 


282 







The morbidity in the Intern Deiiaitmcnt works out at 
4.25 per cent. This is less than in the previous yeav, but 



By Sir W. JSmylv, Dus. Pukefoy and Tweedy. 



23 



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Clinical Report of the Rotunda Hospital. 



still somewhat above our most favourable record. The 
standard adopted in estimating the morbidity is that 
advised by the British Medical Association. By it a 
patient is considered morbid if her temperature reaches 
100° F. on any two occasions between the 2nd and the 
8th day. Abortion cases are omitted from this category, 
and all deaths irrespective of temperature are entered as 
morbid. The temperature is taken in the mouth by a 
ha.lf-minute thermometer, which latter is advised to be 
retained in the mouth for at least three minutes. Further, 



Intern Department. 
Table No. I. — Total Admissions and Deliveries. 



— 


Nov. 


Dec. 


.r.-m 


Feb. 


Mar. 


Apr. 


May 


June 


July 


A M.S. 


Sept. 


Oct. 


Total 


Total deliveries - 

Patients admitted 
not in labour - 

Total admissions 


140 

26 

166 


149 

25 

174 


161 

38 


162 [ 176 
38 25 


165 
35 

200 


196 

45 
241 


179 

26 

205 


205 
23 

228 


181 

40 

221 


189. 
25 
213 


167 
27 


2,070 
373 


199 


200 


202 


194 


2,443 



the temperatures are to be taken as close to 8 a.m. and 
5 p.m. as possible. It is necessary to give these par- 
ticulars with accuracy, for in an excellent report published 
by a leading maternity hospital in England the authorities 
state that they record their morbidity by this method, 
and interpret it as meaning that the temperature must 
reach 100° on two consecutive occasions before the patient 
is to be considered morbid. It should read " on any two 
occasions," not " on any two consecutive occasions." 
The reason for adhering to this plan for lecording morbidity 
is that it has received the sanction of the British Medical 
Association and has been widely adopted. In practice it 
has not proved a very ac(uirate criterion of disease, and 
for guidance in dealing with our individual patients we 
rely upon oui- temperature and pulse standard. Thus, 
no patient is discharged as well who shows a pulse of over 



By Sik W. Smyly, Dhs. Purefoy and Tweedy. 25 

Tablk No. II. — Nature and Number of Cases I'reated. 



Total admissions - 


2,44:! 


Operations — co>k 




Total deliveries 


2,070 


Episiotomj' 


1 


Priraiparse 


71)] 


Suture of perinseal lacera- 




Multiparae 


1,279 


tions 


555 






Complete 


2 


Presentations — 




Incomplete 


553 


Vertex, normal rotation - 


1,9(J1 


Suture of cervical l.-M;era- 




„ face to pubes 


21 


tions 


2 


Pace 


9 


Forceps - 


96 


Brow 


3 


Version - 


18 


Breech 


48 


Caesarean section 


14 


Transverse 


13 


Pubiotomy 


3 


Twins 


29 


Manual removal of placenta 


28 


Triplets 


1 


Laparotomy for ligature of 
ovarian vein 


1 


Complications of pregnancy— 
Hyperemesis 
Hydramnios 
Abortions and miscarriages 


2 

8 
75 


Supra- vaginal hysterectomy 
associated Avith Caesarean 
section 


1 


Haemorrhages — 
Unavoidable 
Accidental, internal 


8 


Morbidity (B. M. A. standard) — 
Average . 1 in 23.52 
Percentage - 4.25 


Accidental, external 


6 






Postpartum 


18 


Mortality — 








Total " - 


5 


Lacerations of perinseum - 


555 


Average - 1 in 


414 






Percentage 


.24 


Contracted pelvis - 


21 


Foetal abnormalities — 




Placental abnormalities — 




Ascites 


1 


Adherent - 


28 


Anencephalus 


2 


Prsevia 


s 


Cleft palate 


2 






Hare lip - 


1 


Prolapse of cord 


(i 


Exomphalos 


1 






Spina bifida 


4 


Accidental complications — 




Talipes - 


1 


Phthisis - 


2 


Teratoma 


1 


Myoma of uterus - 


r 


Hydrocephalus - 


1 


Cardiac disease 


1 






Eclampsia 


9 


Infantile complications — 




Phlegmasia 


1 


Cephalhsematoma 


2 


Mastitis 


6 


Imperforate anus 
Melaena 


1 


Operations — 




Ophthalmia 


3 


Pelvimetry 


17 


Icterus neonatorum 


1 


Induction of labour 


7 


Goitre 


1 i 



26 Clinical Report oj the Rotunda Hospital. 

90, with a temperature of over 99°, within the twenty -four 
hours before dismissal, or in other words for three records. 
The toxsemias of pregnancy are conditions of the utmost 
interest to us, particularly as the treatment which has 
been adopted for some time in the Rotunda Hospital has 
proved uniformly successful throughout the year. Under 
the toxsemias we group hydi'semia, pernicious vomiting, 
accidental haemorrhage and eclamjosia ; nine cases had 
convulsions with no maternal mortality. The smallness of 
the number is, we think, largely attributable to our 
prophylactic treatment for the toxsemias of pregnancy. 



Table No. III. — Pelvic Presentations. 



Para Total 


Dead Children 


Kbmarks 


Primiparse 


23 

25 
48 


Kecent 1 
Macerated 4 

Total 5 


One associated with twin 

pregnancy 
One associated with eclampsia 


Multiparse 

Totals 


Recent 4 \ 
Macerated 3 
Total 7 j' 
Total 12 1 


One associated with twin 

pregnancy 
One associated with perforation 



Of these toxaemias we attended a considerable number, 
and had any of the patients died, even though they did not 
develop fits, they should have been included in our 
mortality table of eclampsia. In treating these cases we 
have reverted to the methods in vogue during the years 
1909-10, and we are now able to show a series of 50 
eclamptics thus treated in the Rotunda Hospital with no 
maternal mortality. These figures should arrest attention, 
for they represent the best results ever obtained in tlie 
Rotunda Hospital. Tt has been suggested that we have 
to deal with a inilder condition than is seen elsewhere. 



By Sir W. Smyly, Dhs. I'uukfoy and Twkhdy. 



27 



But such a view is not tenable, because not only do the 
past statistics of the Hospital disprove it, but we under- 
stand also that the other Dubhn maternities have not 
been able to reach such fortunate results. Whatever 
difference may exist between us as to the iiitiology of the 
disease, there is none in respect to the treatment. This 
consists of — (1) abstinence from all food, including 
milk or Avhey. (2) Lavage of the stomach and lower 
bowel, the introduction of large quantities of alkaline fluid 
into the system through the mouth, if the patient 
is conscious ; and if unconscious, per rectum and 
by subcutaneous infusion. Salt solution should never 
be given, and the alkaline solution should be continued 
so long as polyuria is present, or, what is worse? 



Table No. IV. — Twins. 



Both males 
Both females 
Male and female 
Tocal 



9 
10 
10 
29 



anuria. (3) Large doses of morphine, beginning with 
I grain hypodermically, and continuing the administration 
of \ grain doses every two or three hours until symptoms 
abate, or until 2 grains have been administered within 
twenty-four hours. (4) Warm poultices to the loins. 
(5) Patient must be continuously placed on the right side 
to allow fluids formed in h6r mouth to trickle hito the bed 
rather than into the lungs. (6) Should fluid lodge in the 
pharynx, it will cause much difficulty in breathing, and 
sometimes give rise to fatal asphyxia. To remove it the 
patient's head should be draAvn over the side of the bed 
and turned face downward towards the floor. It is as a 
rule quite safe to deprive a toxic patient of all nourishment 
for at least a week, and when food is again started, it 
should be administered in very small quantities. 



28 



Clinical Report of the Rotunda Hospital. 



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30 Clinical Beport of the Roiunda Hospital. 

Atropine is as a rule combined with nioi-pliine. Labour 
is not induced as a routine, but is frequently terminated 
by means of forceps. 

Purges are freely giv^en, and as a rule by means ot the 
stomach tube. 

Croton oil or other drugs when placed on the back ot 
the tongue may enter the windpipe and act as a deadly 
irritant to the lungs. 

If a patient should recover from fits, we do not consider 
the condition eclamptic unless albumen has been present 
in the urine and unless there is absence of a history of 
chronic kidney disease and of former fits unconnected 
with pregnancy. 

Hyperemesis and other forms of toxaemia have been very 
successfully treated on similar lines. 

In one instance a Caesarean section was performed for 
concealed accidental haemorrhage combined with oedema 
and albuminuria. And we are inclined to view most cases 
of accidental haemorrhage as toxaemic in origin. 

Finally, the more this treatment is adopted as a routine 
and the less it is permitted to the assistant to treat each 
case on its merits the more satisfactory the results will 
prove. 

There were eight cases of unavoidable haemorrhage, in 
four of which the placenta was situated centrally. In 
five cases bi-polar version was performed, two were left 
to nature, and in one the forceps was applied, the os 
being dilatedancl the head presenting. All the mothers 
recovered, and two children were born alive. 

There were five cases of external accidental haemorrhage. 
The vagina was plugged in every case, and all the mothers 
recovered. Two of the children were born alive. 

In one case concealed hannorrhage occurred, the details 
of which are mentioned elsewhere. 

J*rolapse of the cord occurred in six cases ; all the 
mothers and four of the children survived. 

Forceps was applied on ninety-six occasions. 



By Sill \Y. Smyly, Drs. Purkfoy and Twekdy. 31 






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36 CHnicol Beport of the Rohinda Hnspital. 

Caesarean section was performed fourteen times, twelve 
of the children being born alive. In one case of myoma, 
in which the aseptic condition of the patient was un- 
certain, the uterus was removed by the subtotal method. 

In three cases pubiotomy was performed, particulars 
of which are to be found in the Appendix. 

One patient, a 3-para, upon whom pubiotomy had 
been performed in her first confinement, delivered her- 
self without assistance, 

{To be continned.) 



PERISCOPE. 

GALYL. 

Dr. Batchelor {New Zealand Medical Journal, Vol. XV., 
No. 65) reports that he has used this drug some twenty times, 
" mostly for syphilis, and in one case of pernicious ansemia;" 
The therapeutic results were satisfactory, "just as good as 
from salvarsan or neosalvarsan." In two cases, however, 
treated by intravenous injection, alarming symptoms resulted. 
A girl got 0.45 grm. in lOc.c. distilled water — suddenly became 
faint, cyanosed, had a pulse of 160, and complained of an 
intense pain over her heart. The second case — a man, thirty- 
five years old, got a 0.6 grm. in 10 cc. of 4 per cent, safine 
solution , He almost instantaneously became faint, complained 
of intense pain over his heart, had no corneal reflex, his pupils 
were dilated and fixed, and he became of a deathly white 
colour. He appeared as if dead. A hypodermic injection was 
given ; in a few seconds he began to breathe, his colour 
improved, the pulse returned, and within half an hour became 
normal. The author believes that the ill-effects were due to 
the injection of a too concentrated solution. Galyl is the 
tetraoxy-diphosphamino-diarsenobenzene of Dr. MounejTat, 
prepared in 1014. It contains 33.3 per cent, of arsenic ; is 
freely soluble in weak alkaline solutions. Drs. Beurman 
and Tauton have tentatively prescribed the remedy for syphilis. 
And from his experience with it on twenty-one cases Dr. 
Troisfontaincs foiutd that intravenous injections produced 
a temp)rary elevation of teinjx'ratiuc, a temporary headache, 
and sometimes purging and vomiting. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Operative Midwifery. A Guide to the Difficulties aiid 
ConiplicatioHs of Midwifery Practice. By J. M. 
MuNRO Kekk, M.D., CM. (Glas.); Fellow of the 
Royal Faculty of Physicians and Surgeons, Glasgow, 
Ac. Third Edition. London : Bailliere, Tindall & 
Cox. Boyal 8vo. Pp. xvi + 7-25, with 308 Illustra- 
tions. 

L)R. MuNRO Kerr has earned the gratitude of the medical 
profession by the publication of his " Operative Mid- 
wifery," and we are glad to welcome a third edition, 
which is well up to the standard of its predecessors, and 
which, we feel confident, will enjoy the same popularity. 
This work has been thoroughly recognised in America 
and on the Continent, and many of its excellent illustra- 
tions have been borrowed for at least one American text- 
book. 

Munro Kerr is a believer in Nature in obstetrics, and 
it is a relief to record this, having read the extraordinary 
and (we consider) preposterous notions of Dr. Reed, of 
Chicago, which were set forth in a recent number of 
" Surgery, Gynaecology and Obstetrics." We shall not 
quote from this article ; it is sufficient to say that this 
crank suggests induction of laboin- in a large number of 
cases combined with instrumental delivery soon after the 
commencement of labour ! 

In the work before us we find that forceps is still the 
choice for delivery of the after-coming head. We have 
tried this method, but have found the manual methods 
simpler and more rapid. While instruments are favoured 
here, the digital method is recommended for intern 



3S Reviews and Bihtiographical Notices. 

mensuration of the pelvis. We hold a deep respect for 
the opinion of the author, whose experience of contracted 
pelves is large, but we consider that this method is not 
altogether reliable, while the Skutsch pelvimeter is essen- 
tially so. 

The treatment for contracted pelvis is minutely detailed 
and the summing up of the use of forceps in pelvic con- 
traction is as follows : — " It appears to me, therefore, 
that forceps should only be employed in exceptional cases 
when the conjugata vera is below 3J inches (8.7 centi- 
metres), and seldom, if ever, when it is under 3| inches, 
and that the instrument should be had recourse to only 
when the head is well fixed at the brim and does not 
overlap, and only after considerable tiiue has been given 
the head to mould. Finally, that very moderate traction 
should be employed." Pubiotomy and symphysiotomy 
are " justifiable — I would even say indicated — when after 
the second stage has been allowed to go on as long as pos- 
siblej, and after two attempts at moderate traction, with 
the patient in the AA^ilcher position, should the pelvis be 
flat, it is found that forceps just fails to bring the child 
down through the pelvis." 

While the author is dogmatic about his own opinions 
he is most tolerant of the opinions of others, and every 
important point in obstetrics is discussed and illustrated 
in a practical manner. 

The volume is well bound and luinted, and the ilkistra- 
tions are beyond praise. It should lind a resting-place in 
every well-e(]uip|»ed library. 

B. S. 



The Pacific Medical Journal. Volume LIX., No. 1. 
January, 1916. San Francisco. 

This number of a very old-established journal opens the 
new vohime with editoiial greetings to the members of 
tlie medical professi()n mid a comparison of the compas- 
sionate and humane ([uality of Medicine with that of the 
ambitious and cruel luilures which are makin" a charnel 



The Pacific Mediail Journal. 39 

house of Europe by tlieir covetous and unlioly ])assions. 
To this follows a paper on " The Treatment of Septic 
Wounds in War by Magnesium Sulphate," by Drs. 
Morison and Tulloch, in which the good results of the 
treatment are soberly and clearly put forward. In the 
terminal decades of tlie seventeenth and throughout the 
whole of the eighteenth century the name " Sal-mirabile " 
was used to designate the sodium salt, it has fallen into 
disuse ; but it might be revived and fittingly given to the 
magnesium sulphate, whose therapeutic value we are only 
beginning to realise. For years past we have been using 
a concentrated solution of the magnesium sulphate 
as a local application for erysipelas, and in no single in- 
stance has it failed to produce good results. The fact that 
magnesiimi ions are normal constituents of the tissues of 
the human body and their power of abolishing the excit- 
ability of all nervous organs indicates how^ useful the 
magnesium salts wall be when we come to a fuller 
know^ledge of their properties. Dr. Tulloch concludes 
that the sulphate, by virtue of its being absorbed with 
difficulty, has certain " advantages over other salts used 
for cleansing wounds by osmosis." "It also appears to 
have the desirable property of interfering with the diges- 
tive activities of pus," and also that " it inliibits to some 
extent the growth of certain bacteria commonly found 
infecting wounds." We may, however, just add that the 
salt has not been shown to possess either a bactericidal 
or an inhibitory power on anaerobic bacteria, which are 
the most common and most dangerous of the toxic bac- 
teria of the trenches. 

The number contains two excellent articles on drug 
abuses. From 213 cases of drug habituation Dr. C. E. 
Troy, of Jacksonville, Florida, found that their origins in 
the order of their frequency were as follows : — " Through 
physicians' prescriptions or treatment personally admin- 
istered, 54.6 per cent. 

"Through advice of acquaintances, 21.6 per cent. 

" Through dissipation, 21.2 per cent. 

" Through chronic and incurable disease, 2.4 per cent." 



40 Reviews and Bibliographical Notices. 

And Dr. Wilbert concludes by saying that the amount 
of opium and coca consumed annuahy in Ilhnois is out of 
all proportion to the actual need for medicinal purposes. 
If this drug habit is the outcome of prohibition, we are 
forced to the conclusion that prohibition is far from being 
an unmixed good. 



A Ma)iual of Surgical Anaisthesia. By H. Bellamy 
Gardner, M.R.C.S. Eng., L.R.C.P. Lond. ; Honorary 
Anaesthetist to the King George Hospital. Second 
Edition. London : Bailliere, Tindall & Cox. 1916. 
8vo. Pp. xii + '2-20. 

It is just seven years since Dr. Bellamy Gardner pub- 
lished the first edition of his " Manual of Surgical 
Anaesthesia." The period has been one of considerable 
activity among workers at the subject of anaesthesia, and 
has been marked by some noteworthy advances in our 
knowledge. Foremost among these advances we may 
place the intratracheal insufflation aneesthesia, and 
Crile's anoci-association, founded on his kinetic hypo- 
thesis of shock. The intratracheal insufflation ana'- 
stliesia which is the outcome of the work of Meltzer and 
Auer, first published in 1909, has proved to be of great 
value. The method being a new one, and the apparatus 
necessary being somewhat complicated, one would expect 
a detailed descri])tion of both, but Dr. Gardner disposes 
of it in a few paragra])hs by giving a synojjsis of Dr. 
Robert E. Kelly's ])a|)er that a])j)eared in the BritisJi 
Medical Journal for July 20, 1912. Considerable experi- 
ence has been gained of the method since that time, and 
one might reasonably have expected at least some indi- 
cation as to where further information on the subject was 
to be found. Any one who wishes to employ this method 
of producing an;vsthesia should be fully conversant of the 
dangers and ])itfalls that surround it. He will learn that 
there is such a rnetliod, but littU; more, from Dr. 
Gardner's book. 



Gardner— J Manual of Surgical Anitidli^sia. 41 

The anoci-association technique put forward by Crile 
and Lower in their book pubUshed in 1914 has not yet 
received universal acceptance, but the principle involved 
is being more and more generally adopted by surgeons, 
with benefit both to their work and to their patients. In 
a' short chapter Dr. Gardner epitomises a paper of Grile's 
that appeared in the Lancet lor July 5, 1913, but he does 
not offer his readers any criticism of the views there ex- 
pressed, or any indication of how far he would recom- 
mend their acceptance. If the anoci-association tech- 
nique is good it is our duty to advocate its general adop- 
tion, and instruct our pupils in the defects of the method. 
If we believe that it is not good it should be rejected, and 
the reasons for our faith should be set forth. In a text- 
book, written "for the student and practitioner of 
medicine," a mere bald statement that such and such a 
method has been advocated is of little value. While not 
prepared to adopt the full technique of C'rile's method, 
we are convinced that there is much of it that is of the 
gTeatest value, and that we should \\ish to be taught to 
every medical student. Various methods of using nitrous 
oxide and oxygen for prolonged anesthesia in major 
operations have been developed as the result of Grile's 
work, but about such methods or their value our author 
gives us no information. 

It is open for our author to retort that the scope and 
limits of his book did not i)ermit of his entering into a 
detailed exposition of methods and procedures the posi- 
tion of which has not yet been established by a general 
consensus of approval. We would point out, however, 
that there is an obligation on a teacher to instruct his 
pupils in the best methods, whether these be new or old, 
and that we must judge of the capacity of a teacher not 
only by the method of his exposition, but also by his 
capacity to select suitable material for that exposition. 
Judged in this way we consider that Dr. Gardner has 
failed, and his book is one we cannot any longer recom- 
mend to our students. 



42 Rernews and Bibliographical Notices. 

Boletin de Medicina c Higiene, Organo de la Sociedad 
Medica de Barranquilla y de las autoridades Sanitarias 
del Departanientu del Atldnticu. Vol. 1. Nos. 1 and 2. 
8vo. Pp. 59. 

This, the first, issue of the " Bulletin of Medicine of 
Colombia " is very welcome, containing as it does a 
number of interesting and instructive articles. It was in 
the Panama province of Colombia that Gorgas carried out 
his scheme for the stamping out of yellow fever, during 
the time when the United States unjustifiably seized the 
Isthmus and held it in open violation of all law, moral or 
civil. In 1914 Colombia, losing all hope of having the 
looted property restored, signed the Treaty of Panama 
and turned her energies to the development of her own 
country. The "Monthly" before us is one of the first 
literary fruits of this immensely wealthy country ; rich in 
minerals and in soil and having a seaboard both on the 
Pacihc and Atlantic Oceans. Livingstone was the first 
who recognised the value of studying geographical patho- 
logy when he noted the ravages of the tsetse fly ; and Dr. 
August Hirsch, first stimulated by liis writing, com- 
menced, in 1800, his well-known " Geographical and His- 
torical l^athology," which was popularised by Creighton's 
translation for the New Sydenham Society in 1883. This 
was followed by Dr. A. Laveran's classic " Paludism," 
which with Pasteur's biological studies laid the founda- 
tion of modern Preventive Medicine, especially of 
Tropical Medicine, hence it is meet and right that the 
Colombian ]3oietin should begin by referring to such 
researches. 

"Dysentery, or Dysenteric Infectious Colitis" is the 
title of a report frou) l^rs. J. E. Calvo and Otalvaro to 
the President of the Medical Society of Barranquilla, 
which is supplemented by an addendum by Dr. A. 
Arango. No account of dysentery, known to us, paints 
the disease in such ap])alling colours. 

Dr. Calvo's duty was to report on the characteristics of 
the prevailing types of ily.sentery then epidemic, the caus- 
ation of the epidemic, and the conditions which favour its ' 



Boletin de Medkina e Higiene. 43 

spread. He savs the cases examined by hiin all occuned 
•n n-ivate practice, ar.d av.topsies were not allowed, so 
that the pathological examination is necessarily incom 
plete. He divides the cases examined into thice 
groups-d) mortal; (2) severe, but not ta al (3) hght^ 
Dvsentery he defines as a syndrome which may be 
S^ced'by various causes, such as bacilli, amceboid 
bodies, spirilla, trematodes, or by a combination ot t.o or 
more of these causes. Of these the bacillus is the pun^ 
cipal cause of the epidemic, especially ^" ^«^«^^^^",^^^^'^ 
countries bordermg the temperate zone. The symptom^ 
and the progress of the protozoan form ot ^y^ente y 
widely differs from those of the acute dysentery ot the 
bacillary tvpe ; there are cases in which microscopic ex- 
amination 'can make a differential diagnosis and others 
in which it reveals a mixed group of organisms. As a 
rule the protozoan form of the disease is neither as serious 
nor as acute as the bacillary. In many cases it was found 
necessary to administer a purgative to procure f^ces 
suitable for microscopic examination; in such cases we 
unfailingly found the amoibic parasite. In the case ot a 
young woman, in whom from the beginning of the ill- 
ness mixed organisms were found m the faeces the tem- 
perature was from 103° to 104°; death resulted m fit een 
days, during which time she suffered dreadfully: 
emetine, anti-dysenteric serum, and anti-streptococcic 
cultures gave no relief. As a rule the dysentery com- 
menced with purging, malaise, and more or less severe 
pains in the bellv. Some few hours later, blood-streaked 
mucus was passed at stool. The purging increased -m 
frequency, tenesmus and colicky pains became more vio- 
lent and with this there was an alarming rise in tempera- 
ture'. In every case after an interval of twenty-four or 
thirty-six hours the stools consisted of pure blood, or of 
blood mixed with uncoloured mucus. Children, when 
attacked, suffer from green, inodorous, liquid stools with 
mucus and blood-stained fibres. Abundant at first, and 
more or less frothy, the stools gradually became more fre- 
quent and less copious; finally, the purging ceased and 



44 Reviews and Bibliographical Notices. 

the rectal mucous Jiieiiibrane was inteiiiiitteiitly pro- 
truded and retracted. In adults, as in children, there is 
a marked rise in temperature, not infrequently reaching" 
104°. In their general aspect, and rash, they present a 
typical appearance. 

In some cases the following abnormalities were 
found : — 

(1) The absence of fcetor from the stools. 

("2) In such cases as terminated fatally : the pulse from 
the beginning of the illness was feeble and quick, the 
heart sounds indistinct, and the contractions weak. 

(3) Children passed purulent fcieces, the body tem- 
perature was high, but the extremities were cold, with 
dulness, delirium, strabismus and vomiting. 

The epidemic of dysentery which broke out in Barran- 
quilla, and which actually scourged other centres of 
population in the Department, was not of the amcebiform 
type ; the most scrupulous microscopic examination failed 
to find any amoeba'. The one exception was that of 
the young woman whose case is given. As in mixed 
and bacillary forms, emetine, that specific and infallible 
remedy, demanded by the patient and his friends, neither 
modified the symptoms nor stayed the progress of the 
disease. 

One of the most interesting notes is that in reference 
to the " Goat Test," which consists in the injection of a 
stool of the sick man into the rectum of a kid. If the 
dysentery is of the ama.'boid ty[)e, the kid is ill for two or 
three days and tlie amcebte are found in his droppings; if 
it is not of the ainouboid .type, the animal remains un- 
alfected. Meticulous microscopic examination conlirmed 
the coirectness of this extraordinary test. The author 
describes with much fuhiess the ])rocesses of his bacterio- 
logical examination, which dilfer in no marked way from 
text-book formula. The Prefect of the Province pub- 
lished an analysis of the water ; the specimen taken from 
the aqueduct was rich in colon-bacillus, but was quite free 
froni all forms of bacteria and amcjeba; in the basin. 

He concludes — (1) We found no dysenteric bacillus. 
(2) We found the colon bacilli and another agent — a form 



Dritmmond — Phj'^iology for Nur.'ie.s. 45 

of microbe. (3) We found the anti-dysenteric serum a 
valuable auxiliary to other treatment. (4) The toxic 
bodies are conveyed by water and by flies. (5) The epi- 
demic cannot be described as one of bacillary dysentery, 
but as an infectious form of colon bacillo-enterocolitis. 

In the following article Dr. Troconis reports a case of 
poisoning by 10 grammes of the tincture of nux vomica. 
Tlie principal points of the case are as follows : — A 
labourer, thirty-two years old, was found in bed with 
strong flexor contractions of the legs upon the trunk, the 
head extended, the facial nuiscles slightly contracted, and 
the arms normal. Pulse strong, temperature 103°, respi- 
ration normal, pupillary reflex normal ; passed w^ater. The 
spinal column was tapped, 6 c.c. of fluid drawn off, and 
1 c.c. of a 2 per cent, of stovocaine injected; this being 
preceded by a subclavian injection of 200 grammes of 
physiological serum. The stovocaine injection was im- 
mediately followed by a return to the normal state of the 
muscular and respiratory systems. Twenty-grain doses 
of chloral hydrate were prescribed, and in a few days the 
patient returned to his work. 

The greater part of the remainder of the Monthly is 
occupied by official notification of the sanitary laws, 
which have as their object the calling into action of the 
hygienic laws, recently framed by the Colombian Junta, 
and of the municipal laws which the Alcade of Barran- 
(piilla enforces. We are tempted to print them as a hint 
to those who " wait and see," but space does not admit 
of it, although many people might easily recognise how 
superior their hygienic laws are to those familiar to us. 



Physiology for Nurses. By W. B. Drummond, M.B., 
CM., F.R.C.P. Edin. London: Edward Arnold. 
1916. 8vo. Pp. xii + 210, with 81 Illustrations. 

Anyone w1),o has tried to teach elementary anatomy and 
physiology to nurses knows the extreme difficulty of the 
undertaking. What is to be taught, and what is to be 
left untaught, what is elementary and what is advanced, 



46 Reviews and Bihliographical Notices. 

these are questions that are difficiiU. to solve. Even when 
a sohition has been found our difficulties are not at an 
end, for it is no easy matter to teach the elementary 
while we avoid the advanced. An unwise principle 
appears to be growing up amongst us that it is sufficient 
for a teacher of elementary subjects to have merely an 
elementary knowledge of those subjects. The members 
of the Rociety of Jesus, who are world-famed as teachers, 
are said to have a better plan. They are said to hold that 
the most advanced and experienced teachers should be 
devoted to the teaching of the most junior pupils, while 
the less experienced teachers instruct the more advanced 
pupils. 

To all teachers of elementary anatomy and physiology, 
whether they be experienced or inexperienced. Dr. 
Drummond's book will be welcome. It will be useful in 
telling the teachers what should be taught, and it will 
help the pupils to assimilate the teaching. The want of 
really good elementary text-books for nurses has, we 
believe, materially hampered their education, and so their 
usefulness. It would seem as if the dawn was breaking 
of better things for the education of nurses. We sincerely 
trust that it is, and we believe that when the day does 
break its fruitfulness will be materially increased by Dr. 
Drummond's work. We, at all events, shall feel it our 
duty to recommend his book to our nurses, and we believe 
that they will thank us for the recommendation. 



The Charlotte Medical Journal. Volume 72. No. 6. 
Charlotte, N. C. June, 1915. 

This admirable "Monthly" contains, as usual, many in- 
teresting |)apers. " The Treatment of J^^llagra," by Dr. 
Bowling, tells of his experience in the treatment of over 
three hundred cases of the disease. He declares his 
belief in the infectious nature and notiology of the ail- 
ment. He is strengthened in this opinion by the fact 
tbat seventy-five per cent, of his patients suffered also 
from pyorrhoea alveolaiis, and he considers the finding 
of the Thonifison-M'Faddcm Sanatory Commission of the 



The Charlotte Medical Journal. 47 

Commonwealth of ftoutli Carolina on this question effec- 
tually sweeps away the theory of the Zeists. It is agreed 
on all hands that the Commission referred to, which met 
at Spartanburg, South Carolina, where they devoted three 
years to the inquiry, was exhaustive and was carried out 
with an indifference to all preconceived opinions. Dr. 
Bowling without prejudice tried all the more common 
modes of treatment, and he is prone to confess that the 
hypodermic injections of arsenical preparations are not the 
specific remedies we hoped for : Soamin (para-amino- 
phenyl-arsonate of sodium); Atoxyl (meta-arsenate of 
anil). Of the newer preparations he tried injections of 
pituitrin and of auto-serum, and hydrochloride of eme- 
tine. Finally, the treatment consisted of drachm doses 
of castor oil at bedtime and chlorine water in tea-spoonful 
doses every two hours during the day. He has found 
hypodermoclysis of normal saline solutions very useful in 
some severe cases. He has seen this " bring round some 
cases that indeed looked desperate." 

Dr. Black reports the removal of an ovarian cyst, 
which weighed eighty-five (85) pounds. The patient was 
a white woman, aged 57 years, the mother of six children. 
Tn her seventh pregnancy she miscarried at the fifth 
month, when she was five-and-thirty years old. She first 
noticed an abdominal enlargement about two years prior 
to her admission to hospital, to which she was admitted 
on the 21st of July, 1915. Her history was negative. 
Circumferentially the abdomen measured at the ensiform 
cartilage thirty-eight inches, at the umbilicus forty-nine 
and a half, and at the pubes forty-five. The patient 
weighed one hundred and seventy-one and a half pounds 
(171i^). Three days after admission she was tapped, four 
and a half gallons of fluid being removed. Six days later 
a laparotomy was performed, the cyst was tapped, and 
three gallons of fluid were drawn off. The pedicle was 
clamped, ligated, and cut. The sac itself, after all fluid 
was removed, weighed nine and a half pounds. The 
patient made an uneventful recovery. In two columns 



48 Reviews and Bibliographical Notices. 

this highly interesting and instructive case is told, but 
before the two columns are reached the reader has to 
wade through five coUimns of forewords of text-book 
matter, which might intimidate many and please few. 



Modern Medicinf aiul some Modern Remedies. Practical 
Notes for the General Practitioner. By Thoimas 
BoDLEY Scott, Author of " The Eoad to a Healthy Old 
Age." With a Preface by Sir Lauder Brunton, 
Bart., F.B.S. London: H. K. Lewis & Co., Ltd. 
1916. 8vo. Pp. XV + 159. 

We have always held the opinion that the general prac- 
titioner occupies a much more responsible and difficult 
position than the consultant. He is often either over- 
worked or underpaid, or both, yet he is expected to re- 
cognise and treat the various ills to which the flesh is 
heir, any one group of which occupies the whole time of 
the specialist. He may leave a difficult maternity case, 
which would tax the skill of the ablest obstetrician, to 
treat a patient with some obscure nervous disorder, or to 
recognise some urgent abdominal trouble that calls for 
instant surgical aid. To be a good general practitioner 
demands ability of a high order, and we are glad to think 
that there are many such good practitioners in the 
country. 

When to his multifarious duties the general practitioner 
is able to add the recording of his experiences, his book 
is generally worthy of careful study. The four essays here 
published by Dr. Scott are no exception to this rule, and 
we heartily commend their study to nil who are interested 
in the welfare of their patients. The essays deal with 
" Disorders of the Heart," " Arterio-sclerosis," " Thera- 
peutic Speculations and Doubts," and "Chronic Bron- 
chitis and Bronchial Asthma." One and all they are 
admirable, not only for what they teach , but for the sug- 
gestions tlmt they give for further study. 



Hraia — PdtlioUxjical LyiiKj, Acrufiatiou and Swindling. 

CRIMINAL SCIENCE MONOGRAPH No. 1. 

Pathological Lying, Accusation and Sirindling : A Study 
in Forensic Psychology. By William Healy, A.B., 
M.D., Director, Psychopathic Institute, Juvenile 
Court, Chicago, Associate Professor, Nervous and 
Mental Diseases, Chicago PolicHnic, Author of " The 
Individual Delinquent; and Mary Tenney Healy, B.L. 
London : \Yilliani Heinemann. 

The title-page of this very interesting volume bears no 
date, but the subscription to the author's preface is 
accompanied with that of June, 1915. The production of 
the work represents, of course, a characteristic feature of 
the combined scientific materialism and philanthroi)ic 
mental dissection — of the attempted reduction of the phe- 
nomena of mind to the quantitative estimation of weight 
and number that regulates our dealings with matter for 
application (with the highest altruistic purposes) in the 
immediate future — which so eminently distinguishes all 
twentieth century exploration in the domain of patho- 
logical psychology. Since Wohler successfully .broke 
down, some ninety years ago, the previously impregnable 
barrier between the organic and the inorganic kingdoms 
of Nature, the aggressive hopes of the advocate of the 
mechanical conception of the Universe and its Creation 
have been continuously enimciated with progressively in- 
creasing vigour, and reverberated from the cosmopolitan 
audience with correspondingly increasing confidence. 
The self-satisfying "scientific" movement and its over- 
weening aims — being human — have led to many com- 
prehensive blunders of opinion and action ; but it cannot 
be denied that they have also led to broadcast distribution 
of seeds of thought and inquiry which have borne a har- 
vest rich in fruitful results of unprecedented value. 

One of the inevitable productions of such distribu- 
tion of the intellectual view-points and mental orien- 
tation of our (more rapidly revolutionary than progres- 

D 



50 Review.^ and lUhliogmpJiicd] Noiicm. 

sively evolutionary) mechanical age has heen the out- 
cropping movement, of which the present interesting 
vi^ork illustrates the tendency ; the professed aim of 
which is to reduce all the phenomena of pathological 
morality to the formulae of biometrical biology and 
mathematical mechanics. This practical concept is sure 
to "hook" on tenaciously, at least for a time. The 
"greatest of English thinkers'" discussed, with philo- 
sophic earnestness, the question : " Why men love 
lies? " — we must regretfully add, without any more 
definite result than tlie production of an impressively 
readable essay. And the subtlest of French cynics taught 
his readers that a metaphysical discussion could be recog- 
nised, even at a moderate distance, by the featuring facts 
that the party addressed seevied to understand the 
language of the speaker, while the latter did not under- 
stayid it himself. Still the hyperbolic curve evermore ap- 
proaches the outlying parallel to its axis, although never 
able to attain it, and the tj'pe of inquiry of which the 
present volume is a product deserves continuous and 
broad-minded encouragement, for it necessarily opens 
up new vistas of future progress at every step of its ad- 
vance. The characteristic features and data of patho- 
logical lying and swindling should be made readily recog- 
nisable by all intelligent readers, and more especially in 
an age and generation when every man is " out " for 
himself; " and in a country like our own, wdiere even in 
most peaceable times, the statements — professed opinions 
— of even professional experts are often accompanied by 
a creepy mesmeric suggestion that they would — in case of 
expressed contradiction, or even implied doubt — receive 
the requisite corroboration, not from a cerebral store- 
house of assorted facts and of a razor-edged logical 
acumen, but from and by the Nasmyth momentum 
generated in a hypertrophied brachial plexus and the 
muscles thereby motivated. 

In conclusion, we strongly recommend this volume as 
an inspiring store-house of interesting and well-selected 



Hoffman — The. Mortality from Cancer. 51 

facts. And the arguments are always so clearly stated 
that even when we do not agree with the conclusions of 
the authors, we can never fail to derive inspiring sugges- 
tions from their perusal. 

K. 



The Mortality from Cancer throughout the World. By 
F. L. Hoffman, LL.D., F.S.B., F.A.S.A., &c. 
Newark, New Jersey : The Prudential Press. 1915. 
8vo. Pp. 826. 

Dr. Hoffman, the author of this useful book of reference, 
is an Associate Fellow of the American Medical Associa- 
tion and Statistician to the Prudential Insurance Co. of 
America. This latter position admitted of his engaging 
in continuous and exacting labour of compiling, arrang? 
ing and editing the immense mass of statistics. And we 
must acknow^ledge that the book throughout testifies to 
his unremitting toil. He has laid English and German 
literature under tribute, and occasionally, though very 
occasionally, dips into French medical literature, and 
once or twice quotes an Italian journal. Yet he un- 
accountably ignores Spanish, Portuguese, Norse, and 
Russian journals. Valuable as are the statistics given, 
we cannot see how they justify the spreadeagle title 
" throughout the world." Being unread in Medicine, he 
quotes Sir Thomas Oliver's references to gardeners" 
cancer, which is no more than Percivall Pott's clinical 
and classic picture of the maladj- published one hundred 
and sixty years ago. Such a want of familiarity with a 
great surgical classic shakes the reader's faith in the 
author. Withal, the book meets a gTeat want in medical 
literature, and can stand the test of impartial criticism. 
There is no claim for originality; but great research and 
an excellent system must be recognised and acknow- 
ledged. Of the nine chapters which form the first section 
of the book (the remainder consisting of charts, appen- 
dices, bibliography nnd indexes), the first treats of the 



52 Revit'ivs and Bibliograplikal Notiees. 

" Statistical Method in Medicine," the second on the 
" Statistical hasis of Cancer Eesearch," the third on the 
"Increase of Cancer," the fourth on the " Mortality of 
Cancer in Different Occupations," the fifth on " Cancer 
as a Problem in Life Insurance," the sixth on the " Geo- 
graphical Incidence of Cancer," the seventh, "Cancer 
in American States," the eighth, "The Frequency of 
Cancer in Foreign Countries," and the ninth consists of 
" General Observations and Conclusions on the Cancer 
Problem." The issue of this useful book as a free gift 
to medical libraries is a generous contribution to Medi- 
cine, and one well calculated to stimulate further research 
and increased chnical study of this terrible disease, which 
is ever with us : the dread of all who are free of it, and 
an appalling horror to its victims. We hope that the 
author will see his way to the publication of an inex- 
pensive edition, so that the book may become more 
generally know^n to members of the medical profession, 
and, consequently, more beneficial to the general public. 



Archives of tlie Middlesex Hospital. Clinical Series. 
No. XV. (Being the Thirty-fourth Volume of the 
Archives.) Edited by W. Sampson Handlf.y and 
Victor Bonnev. London : Macmillan and Company, 
Ltd. December, 1915. 8vo. Pp. 116. 

The present number of the "Archives" opens with 
" Short Notes on a Case of Systemic Hfmmolysis," by 
Dr. W. Pasteur and Dr. Wliittingham, and is a good 
clinical picture of the disease in a single, poor needle- 
woman of fifty-six years. This is followed by an interest- 
ing " Study of t\w Heart MuKcle, in Health and in 
Disease, by means of the Blectrocardiogra|)h," by Dr. 
G. E. S. Ward, illustrated by eleven beautiful tracings. 
It is a paper which well repays study as being hel])ful in 
the study of all forms of arrhythmic^ action of the heart. 
The remainder of the number is made up of the reports 



Crichton- Browne — Bernhardi and Creation. 53 

of the different registrars, all of which could be made very 
valuable to the practitioner ; but as issued they are almost 
worthless to the student of medicine, consisting as they 
do of unreadable tables followed by scrappy annotations 
which are in no sense informative, though the preface 
states that it is the object of the editors to make the 
Archives " "a real help to old students of the school in 
dealing wdth the complex problems of everyday practice." 

BernJiardi and Creation: A New Theory of Evolution. 
By Sir James Crichtox-Beowne, M.D., D.Sc, 
LL.D., F.R.S. Glasgow: James Maclehose & Sons, 
Publishers to the University. 1916. 

The distinguished author of this booklet can well lay 
claim to the distinction connoted by application of the 
term : A Grand Old Man of Scientific Exposition. For 
there is surely no living speaker or writer of the English 
language who possesses in higher degree the truly in- 
estimable gift of transmitting the most abstruse ideas of 
the most recent scientific thought to the average intelli- 
gent lay reader in such a way that the latter cannot mis- 
take the intended meaning, and of flashing on the cinema 
screen of intelligent public mental vision clearly-defined 
pictures df the respective factors — with their functions 
and results — which take part in the multiplex pernnita- 
tions and combinations of natural history and philosophy. 

In the present instance the most generally diffused 
of current human wave-movements has furnished our 
veteran, and ever verdant, teacher with a new theme — 
so endless in its possibilities of extension as to furnish au 
opportunity of displaying a peculiarly impressive specimen 
of his consummate skill in the practice of the excessively 
difficult operation of successful compression — without 
production of surface creasing, distorting refraction of 
medium, or colouring or opacity of the latter as a result 
of the artificial increase of density. 

Our author has elected, with the inspired skill of a past 
master, to standardise the horrors of militarism and its 



54 " Reviews and Bibliographical Notices. 

votaries by the cubic measurements of Darwinism and its 
apostles. Bernhardi has, as all readers of course well 
know, ordained himself the evangelist of the former creed, 
as did Darwin for the (originally) very startling gospel of 
evolution and " the struggle for existence." And in the 
opening of his discussion of the leading views involved, 
our author does not neglect to point out that Bernhardi's 
famous (or infamous) book begins with a study in evolu- 
tion — while the writer " has grossly misapprehended and 
misinterpreted Darwin's position." — Here we feel that 
we must check ourselves, for we know but too well that, 
in order to express in full our. appreciation of the contents 
of this booklet — not being possessed of the author's gift 
of compression — we should be obliged to write something 
far longer, and infinitely less instructive and less read- 
able, than the whole of his own text. So we will abruptly 
close our notice by recommending to the special attention 
of all cultured scientific readers an exquisite critical view 
of the i)hilosophy of German destructive militarism on 
the one hand, and that of British creative Darwinism on 
the other. 



Notes on the Technique of Effective Bromide Therapy in 
Epilepsy. By Dr. A. Ulrich. Translated by F. C. 
Barlow, L.R.C.S. & P. Edin. 8vo. Pp. 28. 

This pamphlet of twenty-eight octavo pages is neither 
less nor more than an advertisement for " Sedobrol," a 
proprietary drug of Messrs. Hoffmann La Jioche. The 
advertisement is served up with a wonderful amount of 
stuffing of the pseudo-scientific type, which is the 
nutrient of all quackery. Gardette, pages 301-80'2. de- 
scribes " Sedobrol " as extract of beef free from chlorine 
but bromated, and devotes only ;> few Hues to its de- 
scription and use, in his T2mo vohinie for 1914. Tt is 
painful to think that members of the medical profession 
lend themselves to such advertisement. 



PAKT 111. 
MEDICAL MISCELLANY. 



Reports, Transaciions, and Scientific Intelligence. 



DUBLIN DURING THE REBELLION. 

We reprint from The Nursing Mirror and Midwives' Journal 
of May 13, 1916, the following graphic story of the Sinn Fein 
Rebellion of Easter week as observed by Queen Victoria's 
Jubilee Nurses at St. Patrick's Nurses' Home, St. Stephen's 
Green, Dublin. The writer is Miss Christabel Crowther, Lady 
Superintendent of the Home. 



Introdtjction. 

During the past year superior persons arriving from England 
reminded us of our immunity from the shadow of war. Many 
who have inwardly chafed at the obvious call of duty which 
kept us stoking the '' home fires," instead of going forth to the 
much more attractive war work, felt the partial truth of their 
jibes and the sting thereof, so that sometimes the task of 
nursing the sick poor in their own homes, \vith only an 
occasional convalescent or disabled soldier to give it colour, 
became rather dull. 

Real War. 

In Easter week the reproach was removed. War — no 
shadow, but real war, with armoured cars and machine guns, 
trenches and barbed %vire — came to us unsought. At noon 
on Easter Monday St. Stephen's Green, which, as most people 
know, is a sort of glorified edition of the garden in a London 
square, was taken possession of by the insurgents. They dug 
trendies and hid themselves therein, or lay down flat under 
the budding lilacs, pointing their rifles outwards through the 
railings, and it was only when they began to fire recklessly at 
the passers-bv that we realised it meant something more than 



56 Dublin during the Rebellion. 

holiday manoeuvres, so accustomed are we in Dublin to the 
Sinn Feiners and their demonstrations. By 1.30 the attack 
was in full swing. 

Our first patient was a policeman, shot a few paces from 
our door. He was fatally wounded in the chest, and though 
we ran to him with all speed, carrying dressings, &c., he was 
past all aid, except such as was being already administered 
by a grey-haired priest. While we stood round, lamenting 
our impotence, but ready to help in any way if needed, an 
ambulance arrived, amid a shower of bullets, and the poor 
fellow was gently taken to a hospital close by. 

Improvising a Hospital. 

Anticipating more work of the kind, we rapidly turned the 
nurses' sitting-room into a very presentable httle hospital 
ward, and I rang up the military authorities, who mercifully 
had control of the telephone, and told them of our willingness 
to help. We made a Red Cross flag out of half a sheet and 
some strips torn from an old red cotton curtain. We fastened 
it to a curtain pole, but fixing it in a front window was one 
of our most difficult tasks. I hoisted it myself mth the aid 
of some strong twine, while a couple of firebricks and a disused 
iron gas stove served as weights. It was hard work to keep 
it from sAvinging round in the fresh breeze, and a whistling 
bullet, unpleasantly near, did not make things easier. I am 
afraid it was a feminine -looking effort at best, but it served 
its purpose. Two of the nurses were told of? for night duty, 
and as we knew we could rely on the help of a kind-hearted 
doctor next door we were soon quite ready for action. 

Meanwhile, as far as possible, we went on with our usual 
work. One nurse tried to get to her district by a m,ain road 
closely guarded by soldiers. She was sternly ordered out of 
danger, and her plea of being the district nurse was met by 
the reply : " We couldn't let you through if you were the 
King of England." 

Recognising the Uniform. 

The uniform of the Queen's Nm-ses was, on the whole, 
however, a safeguard and a good passport ; many of the 
English soldiers recognised it, being u.sed to it in their own 



Dvhlin during the Rebellion. 57 

town>s. The nurses were thus enabled to be of use to less 
privileged friends and neighbours. One doctor and his wife 
arrived home from an outing on the Bank Holiday to find 
their house and dispensary in the hands of the rebels. They 
ascertained the safety ot their children and servants, who had 
been driven out and found shelter at a chemist "s shop some 
streets aw^aj', although they could not get near them. Tlie 
parents were harboured by a brother practitioner, himself a 
prisoner in his own house. The nurses were allowed by the 
soldiers to fetch food for the prisoners, to take messages to 
the children, and help in many ways. A poor man from a 
slum near bj^ entreated the nurses not to go until he could get 
a Red Cross flag, which he did wdth surprising celerity, march- 
ing before them with banner unfurled, proud to take his part 
in the httle drama. 

The Last Offices. 

One morning one of the nurses had to pass along the quays, 
which were guarded by soldiers. She saw the dead body of 
a man lying uncared for in the road. The soldiers told her 
it had lain there for four days, but, being EngHsh and knowing 
nothing of Dublin, they had no idea how to proceed y^nth 
measures for its removal. The nurse took the matter in hand 
herself and settled it in less than half an hour. One case 
brought to our little hospital was a very sad one — a small, 
aged man, wdth snow-white hair and beard, shot at our very 
doorstep a few minutes after I had come in from one of my 
many foraging expeditions. He was the minister of a little 
church near by, and was slo«iy wending his way home when 
he was killed by a shot from the ijubhc-house (occupied by 
rebels) at our corner of the Green. A lady who knew him 
has since told us that she \\'arned him two days earlier of the 
danger, kut he replied : "" Nobody would trouble to shoot me." 

Machine Guns and Incendiary Fires. 

We saw many tierce battles of machine guns between the 
miUtary at the Shelbourne Hotel and the rebels in the College 
of Surgeons. We became so much used to the noise that we 
went on with our daily work \vithout noticing it. Our chief 
anxiety was a fire at the back of the house, and close to us. 



58 Dublin during the Rebellion. 

TJiree shops were soaked vAih. petrol and ignited. A young 
man returning from his ghastly work with an empty petrol 
can in his hand was shot close by our house, and the body 
lay there for some hours. The Fire Brigade, notwithstanding 
continual shots by snipers, got the fire partly under, but was 
called away to the more serious trouble in Sack^^lle Street. 
Our own particular conflagration smouldered all day, but 
showed signs towards evening of brightening up. We rang up 
the Brigade, who expressed regret, but said they were too busy 
to come. This was comforting, especially as snipers on the 
surrounding roofs were making it their business to see that 
nobody extinguished the flames. I stayed up all night and 
kept my eye on the burning houses. However, next morning 
a fire engine did turn up, and after about thirty hours' anxiety 
our minds, on that score at least, were set at rest. 

A Meagre Meal. 

With regard to food we came through surprisingly well' 
Our most meagre dinner was on the Friday — one potato each 
and a helping of rice boiled in water, with a sardine or two 
for some of us. Words fail me to tell of all the dreadful sights 
we saw from our front ^^^ndows. We also saw much that was 
interesting of the rebel tactics. To their credit be it told that 
they sent one of their women across to warn vis not to use 
opera glasses, as it was dangerous. I do not think they would 
hav^e hurt one of us nurses willingly, though I cannot answer 
for all the individual snipers swarming on every hand. The 
fact that of all the hundreds of bullets flying about us for six 
days only two entered the house seems to uphold my belief. 



PERISCOPE. ^ 

HON. SUHGKON OCULIST TO TlIK KIXC 1 X IHIOI.AXD. 

The King has appointed Mr. John Benjamin Story, M.B., 
K.R.C.S.I., to be Honoinry Surgeon Oculist to liis Majesty 
n Ireland, in loom of Mr. ("liiules Edward Fitzgerald, M.D., 



1 
i 
deceased. 



ROYAL ACADEMY OF MEDICINE IN IRELAND. 

President— R. D. Purefoy, M.D., F.R.C.S.I. 
General Secretary— J. A. Scott, M.D., F.R.C.S.I. 



SECTION OF SURGERY. 

Presideut — F. Conway Dwyer, M.D., F.R.C.S.I. 
Sectional Secretary — Sir Arthur Ball, Bart., M.D., 
F.R.C.S.I. 

Friday, April 1th, 1916. 

Alex. Blayney, F.RC.S.I., in the Chair, 

Remarhs on Injuries to Peripheral Nerves. 

M.\JOR F. C. Purser read a paper with this title. He 
showed first what might be expected in a nerve which was 
wholly divided, and then sutured under the most favourable 
conditions. Wounds caused in war seldom had so good an 
ending. They might be divided roughly into two classes, a 
numerically smaller class of total loss of function and a larger 
class where function was not wholly lost. A case in either 
class, but especially in the latter class, might be associated 
with pain or with hyperaesthesia. In the first class, with 
total loss of power and of sensation, the question to make sure 
of in the first instance was that the lesion was organic, of a 
nerve or nerves, and not functional. Having decided this, 
the exact outline of sensory loss and extent of motor loss 
should be recorded. If there was no improvement in six 
weeks or two months, exploration of the nerve was justified. 
Partial loss of function varied in severity of its symptoms 
from a loss almost total to a mere subjective sense of abnor- 
mality. Motor loss, as far as it can be compared with sen- 
sory loss, is often disproportionately great. Improvement 
in the condition of a case may be gauged better by an exact 



60 Royal Academy of Medicine in Ireland. 

examination of sensory changes than elsewhere. Cases were 
described illustrating this. 

Either total or partial loss of function may be due to 
anatomical section of a nerve or to the inclusion of the nerve 
in scar or other compressing tissue. Recovery following 
secondaiy suture was far less satisfactory than that following 
the release of the nerve from scar tissue. 

Operation was called for when the disablement was very 
great, and was not lessening luider proper relaxation and 
massage treatment, and when paui was severe. Often 
enough it made matters worse, and should not be undertaken 
without very careful repeated consideration of the case. 

Bullet Injuries of Nerves and other Treatment. 

Mr. W. S. Haughton read a paper on the above subject. 
He dealt chiefly with the mechanical effects of high velocity 
bullets striking the tissues, and described the different types 
of lesion that resulted in the nerves in the neighbourhood of 
wounds. 



SECTION OF OBSTETRICS. 

President— Gibbon FitzGibbon, M.D., F.R. C.P.I. 
Sectional Secretary — Bethel Solomons, M.D., F.R. C.P.I. 

Friday, May im, 1916. 

The President in the Chair. 

Reports of the Rotunda Hospitals. 

Sir William Smyly read the Rotunda Reports. They are 
])ubhshed in full at page 21. 

Sir a. Horne said he wished to congratulate the Governors 
of the Hospital in granting Dr. Jellett a further extension of 
leave to serve his country with the ambulance work. He 
noted ill th(! present report that s])ecial attention was drawn 
to the excellent results accomplished in the treatment of 
eclampsia. He did not think the disease here was milder 
than elsewhere, but was of opinion that one got cycles 
of mild and serious cases into liospital. He considered it 
important that ante-natal clinics sliould be attached to all 
maternity hospitals, so tliat the toxaemias of pregnancy could 
be recognised early. He regretted there was no mention o* 



Section oj Obsletnes. 

the .ubioot of scopolamine.n,orphine fe.t.nu.nt wl,io\. oc-ou,.u,l 
HO ;S Attention at the present moment in the lay ,, e s^ 
He would also hUe to point out that ^ years ago a ion -e. 

rreZra„"'a^^„ralt.;io^ioT;:,:.r :. o. eon. 

noalpfl aooidental haemorrhage. _ 

ceaiea accuifnta o recollect on a patient 

Dr Bethel Solomons said that in ms recollect ^ f 
jjR. Df.Liiv.u . i-u -R M A standard when the 

was morbid according to the B. M. A. stanaaiu 

^ ?c;:;r:r-::S:^ine an..hesia since the ^ul^t^n 

i^^ShfsiSr-^u::;!^^^^ 

watcar'LdL by tLined assistants ^^^^^^^J^ 
impossible for the ordinary practitioner to adopt it unless he 
Tas prepared to devote his whole time to the case. He asked 
Dr Rowlette to state his opinion of the present position of 
serums and vaccines in the treatment of puerperal sepsis. He 
not'Tthat two of the patients in the Contracted Pelvis Table 
e'; not measured internally. He was aware that the autho- 
tts atthe Rotunda favoured mensuration by the Skutsch m- 
st ument. and he thought it would be a good thmg if there was 
a separate Table devoted to Skutsch pelvimetry as this woxi d 
draw more attention to its use. ^lunro Kerr m his text-book, 
atd also many well-known authorities in ^^^^ ^^ 
where still insisted that manual measurement ot the peUis 
was the best. He noted that pituitary extract wa^ given in 
some cases of accidental hemorrhage. He wished to kno ^ 
the size of the os when the drug was admimstered. He in- 
nuired as to the meaning of three cases of hysterotomy m the 
myomectomy Table-whether the hysterotomy was per- 
formed for diagnosis according to Deaver's extraordmary idea . 
Dr Purefoy said he was not an enthusiast for scopolamine- 
n.orphine anesthesia. Amongst the patients who had died 
of sepsis he recollected that one had not been able to he down 
for three weeks prior to admission because of great distress 
from hydramnios; the labour was slow, pains not ensuing for 
some days after rupture of the membranes. Her aspect from 
her admission was that of a woman dying of pernicious 
anemia. He was a firm beliver in the Skutsch PeW^meter. 
^md regretted that some still relied on the digital method. He 
thought there was no need for intern pelvimetry in some very 



obvious cases. 



02 Floijal Academy of Mediriiie m Jrehmd. 

Dr. Rowlette said he thought that in the treatment of puer- 
peral sepsis, both vaccines and serums should be employed. 
The vaccines should be autogenous, but pending their prepara- 
tion stock vaccines should be used. The use of these agents 
did not preclude any other method of treatment vi'hich might 
be considered advisable in a particular case. They were not 
to be regarded as a cure-all. 

Sir William Smyly, in reply, said there had been so many 
changes in the personnel of the hospital staff during the year 
that it would be impossible to assign the degree of indebted- 
ness to each member who had helped in compiling it, but Dr. 
Simpson had done most of the work in preparing the statistics. 
He was glad that Sir Andrew Home had called attention to 
the ]\Iaster's patriotism in going to France at considex'able 
financial sacrifice, and also to the fact that Dr. Bagot was the 
first operator who had performed hysterectomy in the treat- 
ment of concealed accidental hsemorrhage. Regarding 
scopolamine-morphine he had given directions that one dose 
at least should be given to every patient who was in the first 
stage of labour, but not that it should be pushed to the degree 
described as " Twilight Sleep." As to the insinuation that 
the treatment of eclampsia formulated by Dr. Tweedy had 
been modified in recent j'ears, he very much regretted that Dr. 
Tweedy was not present to defend that opinion. 



RECURRENT EPISTAXIS TREATED WITH FRESH-BONE MARROW. 

A Hindoo farmer, aged twenty, was admitted to hospital 
for very serious epistaxis by Surgeon Goswsemi, Indore. He 
was subject to tliese attacks for the past four years. At the 
time of his admission he bled almost daily. His conjunctivse 
were almost white, cornea dry, and the eyes sunken ; he was 
so weak as to be unable to stand ; oaderaa of his legs and 
spleen much enlarged. Bk)od examination : — Haemoglobin 
40 per cent., R.B.O. 1,001.500, W.B.C. 3,000, Polymorphic C. 
00 per cent.. Large M. 2 per cent., Lymphocytes 20 per cent., 
Eosinophils 2 per cent. On the 1st May, 1914, the fresh-bone 
marrow treatment was commenced, the patient then weighing 
90 lbs. only. On the 31st he weighed 111 lbs., and his hainio- 
globin examination showed 80 per cent., his R.B.C. increased 
to 4,000,000 ; his strength was now sufficient to admit of his 
leaving hospital to resume his ordinary employment. — The 
Indian Medical Jovrnnl. Vol. TX., No. 12. 



METEOROLOGICAL NfTES. 

Meteorology. 
Abstract of Observations made in the City of Dublin, Lat. 53^ 20' 

N., Long. 6° 15' W.Jor the Month of May, 1916. 
Mean Height of Barometor, - - - 29.903 inches. 

Maximal Height of Barometer (18th, at 9 a.m.). 30.387 ,, 
Minimal Height of Barometer (6th, at 9 a.m.), 29.302 
Mean Dry-biilb Temperature, - - 50.9°. 

Mean Wet-bulb Temperature, - - 48.1°. 

Mean Dew-point Temperature, - - 45.1°. 

Mean Elastic Force (Tension) of Aqueous Vapour, .303 inch. 
Mean Humidity, - - . . 81.8 per cent. 

Highest Temperature in Shade (on 19tli). - 71.5°. 
Lowest Temperature in Shade (on 8th), - 37.0°. 

Lowest Temperature on Grass (Radiation) (8th 

and 10th), ----- 35.8°. 
Mean Amount of Cloud, - - - 67.3 per cent. 

Rainfall (on 21 days), - - - 4.634 inches. 

Greatest Daily Rainfall (on 5th), - - 1.816 inches. 

General Directions of Wind, - - - W., ^J.E. 

Remarks. 
May, 1916, was a month of average temperature but of 
heavy and frequent rainfall. It was ushered in by a very 
cold spell, accompanied by wmds from polar quarters, and a 
downpour of rain on the 5th, 6th and 7th. The precipitation 
on these three days totalled 3.175 inches, of that large amount 
1.816 inches fell in the 24 hovirs ended at 9 a.m. of the 6th 
On the Dubhn and Wicklow Moimtains much of the precipita- 
tion was in the form of snow, which lay to a great depth at 
altitudes above 1,700 feet throughout the 8th. 

A bright, dry and warm period prevailed from the 15th to 
the 20th inclusive, the thermometer rising above 70° in the 
screen on three days. After this temperature fell away again, 
and the weather became unsettled with frequent rain or 
showers on and a^er the 24th. There Avere hail-showers on 
the 26th and 28th, and the nignt temperatures were very low 
for tne time of year. Fresh to strong W.S.W. winds blew 
throughout tbe 31st, with some increase of temperature. 

A " smi pillar " was observed on the evening of the 20th at 
Oxford and at Seskin, Carrick-on-Suir. At the latter station 
it was of rainbow colours. 

In Dublin the arithmetical mean temperature (52.1°) was 
0.1° below the average (52.2°). The mean dry-bulb readings 
at 9 a.m. and 9 p.m. were 50.9°. In the fifty 5?-ears ending 



64 Meteorological Notes. 

with 1915, May was coldest in 1869 (M. T. = 48.2°), and 
warmest in 1893 (M. T. = 56.7°). In 1912 the M. T. was 
53.5°, in 1913, 52.3°, in 1914, 52.4°, and in 1915, 52.0°. 

The mean height of the barometer was 29.903 inches, or 
0.086 inch below the corrected average value for May — namely, 
29.989 inches. The mercury rose to 30.387 inches at 9 a.m. 
ot the 18th, and fell to 29.302 inches at 9 a.m. of the 6th. The 
observed range of atmospheric pressure was, therefore, 1.085 
inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 50.9°, or 4.2° 
above the value for April, 1916 — 46.7°. Using the formula 
Mean Temp. = Mi7i.+ {Max. — Min.)xAl, the value is 51.7°, 
or 0.1° below the average mean, temperature for May, cal- 
ciilated in the same way, in the thirty-five years, 1871-1905, 
inclusive (51.8°). The arithmetical mean of the maximal and 
minimal readings was 52.1 '\ compared with a thirty-five years 
average of 52.2°. On the 19th the thermometer in the screen 
rose to 71.5° — wind, S.E. to W. ; on the 8th the temperature 
fell to 37.0° — wind, N.W. The minimum on the grass wos 
35.8° on the 8th, and again on the 10th. 

The rainfall amounted to 4.634 inches, distributed over 21 
days. The average rainfall for May in the thirty-five years' 
1871-1905, inclusive, was 1.970 inches, and the average 
number of rain -days was 15. The rainfall, therefore, and the 
rain -days were much above the average. In 1886 the rainfall 
in May was very large— 5.472 inches on 21 days ; in 1869, 
also, 5.414 inches fell on 19 days. On the other hand, in 1895. 
only .177 inch was measured on but 3 days. In 1896 the fall 
was only .190 on 7 days. In 1915, 1.601 inches fell on 12 days. 

High winds were noted on 5 days. Hail fell on the 26th 
and 28th. There was a fog on the 21st. Solar halos were 
seen on the 10th and 20th, a lunar halo on the 13th. 

The mean minimal temperature on the grass was 43.5°, 
compared with 43.2° in 1.915, 44.5" in 1914. 45.5" in 1913, 
44.5° in 1{)12, 46.2" in 19 II. 42.0 in 1910, 41.9' in 1909, and 
37.6° in 1894. The maximum fell short of 50° on the 5th, 6th 
and 7th. On tlie last-named day the thermometer rose no 
higher than 43.4". The liighest daily minimum was 55.9° on 
the 20th. The mean maximum was 57.8°, the mean minimum 
was 46.3°. 

The rainfall in Dublin during the five months ended May 
31st amounted to 14.648 inches on 105 days, compared uith 



Meteorological Notes. 65 

9.490 inches on 82 days in 1915, 8.132 inches on 85 days in 
1914, 13.899 inches on 91 days in 1913, 11.161 inches on 87 
days in 1912, 5.986 inches on 69 days in 1911, 12.421 inches 
on 92 days in 1910, only 5.971 inches on 70 days in 1896, and 
a thirty-five years' average of 10.040 inches on 81 days. 

Captain Edward Taylor, D.L., gives the rainfall at Ardgillan, 
Balbriggan, Co. Dublin (210 feet above sea-level), as 6.26 
inches on 24 days, the rainfall being 4.35 inches above, and 
the rain-days 10 above, the average. The heaviest fall in 24 
hovirs was 2.46 inches on the 5th. There was a continuous 
rainfall from 7 a.m. of the 5th to 1 a.m. of the 8th, the measure- 
ment being 4.19 inches. The rainfall from January 1st equals 
14.55 inches on 106 days — that is, 4.29 inches above the 
average, while the rain-days have been 27 above the average. 
The thermometers in the screen rose to 71.1° on the 20th 
and fell to 34.7° on the 10th. The May rainfall at Ardgillan 
has ranged from 6.26 inches on 24 daj^s in 1916 to .14 inch 
on 3 days in 1895. 

Mr. T. Bateman, of The Green, Malahide, Co. Dublin, 
returns the rainfall at 5.755 inches on 22 days. The greatest 
fall in 24 hours was 2.295 inches on the 5th. 

The rainfall at StirHng, Clonee, Co. Meath (231 feet above 
sea-level), according to Mr. J. Pilkington's return, was 4.43 
inches on 20 days, the largest fall on any one day being 1.28 
inches on the 5th. On the 6th also, .76 inch fell, and on the 
7th .61 inch — 2.65 inches on three consecutive days. From 
January 1st to May 31st, 16.43 inches of rain fell on 110 days 
at Stirling. 

At the Ordnance Survey Office, Phoenix Park, Dublin, rain 
fell on 18 days to the amount of 4.21 inches, the greatest 
measurement in 24 hours being 1.46 inches on the 5th. The 
total duration of bright sunshine was 163.2 hours, the largest 
amount recorded on one day being 12.9 hours on the 19th. 

At Cheeverstown Convalescent Home for Little Children, 
Clondalkin, Co. Dublin, Miss Mary Love recorded 4.78 inches 
of rain on 19 days. The largest falls in 24 hours were 1 .31 
inches on the 5th, .98 inch on the 6th, .58 inch on the 7th, 
and .57 inch on the 8th — 3.44 inches in 4 days. 

At 89 Anglesea Road, Donnybrook, Dubhn, Mr. F. C. 
Dudley Joynt measured 4.590 inches of rain on 18 days, the 
largest amount recorded in 24 hours being 2.050 inches on the 



66 Meteorological Notes. 

5th. On the 6th .960 inch fell, and on the 7th .540 inch- 
in all 3.550 inches in three days. 

Mr Harold Fayle sends the follomng abstract from Rosedale, 

Shankhill, Co. Dublin :— 

Mean coiTected Height of Barometer, - 29.916 inches. 

Highest corrected reading (18th, 21 hours), - 30.39 ,, 

Lowest corrected reading (6th, 9 hours), - 29.30 ,, 

Mean Dry-bulb Temperature, - - - 50.4°. 

Mean Wet-bulb Temperature, - - 48.2°. 

Mean Vapour Pressure, _ . . .310 inch. 

Mean Humidity, - - - - 86 per cent. 

Mean Maximal Temperature, - - - 56.5°. 

Mean IMinimal Temperature, - - - 43.9°. 

Arithmetical Mean Temperature, - - 50.2°. 

Highest Temperature in Screen (20th), - 66°. 

Lowest Temperature in Screen (8th, 9th), - 36°. 

Lowest Temperature on Grass (4th), - - 25°. 

Nights of Ground Frost, - - - 6. 

Rainfall (on 20 days), - - - - 6.08 inches. 

Greatest Daily Rainfall (5th), - - 2.51 

Mean Amount of Cloud, . _ . 69.2 per cent. 

Days of Clear Sky, - - - - 1. 

Days of Overcast Skj', - - - 14. 

General Directions of Wind,. - - - W., N.W., S.W. 

Rain fall continuously from the 4th to the 7th, the measure- 
ment bemg 4.57 inches. 

Dr. Arthur S. Goff reports that the rainfall at BeUort House, 
Dundrum, Co. Dublin, was 6.11 inches on 20 days. The 
greatest daily rainfalls were 2.28 inches on the 5th, 1.96 inches 
on the 6th, and .52 inch on the 7th, being 4.76 inches for the 
three days. The mean shade temperature was 52.5°, compared 
with a ten years' (1901-1910) average of 46.6°. The thcrmo- 
metric range was from 36° on the 8th to 76° on the 19th. 
The mean shade temperature was 53.1°. 

At Marino, Killiney, Co. Dublin, Mr. W. J. M'Cabc, the 
observer for the Right Hon. L. A. Waldron, registered 4.59 
inches of rain on 20 days. The largest falls in 24 hours wei-e 
1.55 inches on the 5th, .83 inch on the 6th, and .79 inch on 
the 7th — 3.17 inches on three consecutive days. 

Dr. John H. M. Armstrong reports that at Coolagad, Grey- 
stones, Co. Wicklow, the rainfall amounted to 6.84 inches on 
20 days. Tlio heaviest fall in 24 hours was 2.61 inches on the 
5th. Falls of 1.55 Indies and of .93 inch took place on the 6th 



I 



Meteorological Notes. ()7 

and 7th, respectively, making a total of 5.09 inches in three 
consecutive days. The rainfall at Coolagad in 1916, up to 
May 31st, was 19.30 inches on 106 days. Fog occurred on the 
1st, 5th, 6th, 18th, and 21st. The Welsh Mountains were seen 
at 6 20 a.m. of the 27th and at 6 10 a.m. ot the 31st. Lightning 
was observed between 9 and 10 p.m. of the 2nd, and tlumder 
was heard at 2 35 p.m. of the 26th. Tlie thermometer in the 
shade rose to 68'' on the 18th, having fallen to 36° on the 6th. 

Mrs. Sydney O'SuUivan recorded approximately 4.99 inches 
of rain on 20 days at Auburn, Greystones. 

Dr. P. O'B. Kennedy, Resident Medical Officer at the Royal 
National Hospital for Consumption, Newcastle, Co. Wicklow, 
reports that the rainfall at that place was 5.91 inches on 19 
days, the maximal fall in 24 hours bemg 3.25 inches on the 
5th. Tlie mean temperature of the air was 51.0*^, the ther- 
mometer in the screen having risen to 68° on the 19th and 
fallen to 36° on the 7th. The mean maximal temperature was 
56.5°, the mean minimum being 45.4°. 

At the Rectory, Dunnianway, Co. Cork, the Rev. Canon 
Arthur Wilson, M.A., measured 3.46 inches ot rain on 19 days. 
The rainfall was .10 inch less than the average (3.56 inches). 
The heaviest falls Avere on the 6th (.60 inch), 31st (.59 inch), 
and 23rd (.53 inch). The hot spell which began on April 28th 
did not last beyond May 2nd. The weather was cold and un- 
settled from the 5th to the 11th, very warm and hue from the 
15th to the 20th and from the 25th to the 29th. Tlie rainfall 
for the five completed months of 1916 amounts to 24.51 inches, 
or .69 inch less than the average of 11 years (25.20 iiiches). 

ROYAL COLLEGE OF PHYSICIANS OF IRELAND. 

At a special meeting of the College held on Friday, June 
16, 1916, the President and Fellows unanimously adopted 
a resolution urging on the Government the pressing necessity 
which exists for the passing of a Midwives Bill for Ireland, 
which is now tlio only part of the United Kingdom witliout 
legislative control of midwives. Such a bill is needed to 
protect lying-in women, to control infant mortality, and to 
enable Irish trained midwives to take their proper i)lace in 
the ranks of the registered midwives of the United King- 
dom. The Parliamentary Committee was empowered to 
take such steps as may bo deemed necessary to help forward 
such legislation. 



PEEISCOPE. 

IN ARDUIS FIDELIS. 

Motto of the Royal Army Medical Corps. 

" Never for them the awful joy 

That sets the soldier's breast afire, 
The lust to conquer and destroy', 

The blazing passion, mad desire; 
Spurred by no glory to be won, 

Not warmed by battle's heated breath. 
Only a sad task to be done, 

They do their duty — true till death. 

" Denied the pomp and pride of war. 

The peril alone is their's to share; 
Yet, self and safety flung afar, 

They do what mortal men may dare. 
Steadfast in their Christ-given faith, 

All for others, if need, they give ; 
Faithful in danger, true till death. 

They die that fellow-men may live. 

" C. S. B." 

[From Scottish Coantnj Life. June, 1916. Vol. iii. No. 6. 
Page 273.] 

LITERARY INTELLIGENCE. 

The Crown Prince of Serbia has given his photograph for 
reproduction in a book which will shortly appear wTitten 
by Mr. and Mrs. Berry, Mr. W. Lyon Blease, and other mem- 
bers of the party, entitled " The Stor;y of a Red Cross Unit 
in Serbia," and has allowed the volume to be dedicated to 
bim. The book, which is to be published by Messrs. J, & A. 
Churchill, deals with the recent history and the aims of the Serbs 
as well as with the exciting travelling and o^her experiences 
of ths mission, the establishing of hospitals, sanitation, and 
the treatment of a severe epidemic of typhus. It tells of the 
Austrian invasion, and shows how the unit fell into the hands 
of the enemy. The vclumc is illustrated by photographs 
taken by various members of the party. 



|n gUnmriam. 



CHARLES EDWARD FITZGERALD, 
M.D., M.Ch. Univ. Duel. ; 

FELLOW AND EX-PRESIDENT OF THE ROYAL COLLEGE OF 

PHYSICIANS OF IRELAND ; 

HONORARY SURGEON-OCULIST TO HIS MAJESTY THE 

KING IN IRELAND. 

With pained surprise and very deep regret the members 
of the Medical Profession in DubUn learned that one of 
the most distinguished and most popular of their number 
had succumbed a few hours after an operation on the 
afternoon of Saturday, May 27th. Tlie interment, wliich 
was private, took place on the mofning of Tuesday, May 
30th, in the ancient burial ground of the ruined church 
of St. Fmtan, at Sutton, Howth, Co. DubUn. 

Bom in Dubhn on the 9th of February, 1843, Charles 
Edward FitzGerald was the second son of Francis 
xVlexander FitzGerald, Baron of the Court of Exchequer, 
and a Idnsman of the Knight of GHn, an Anglo -Irish 
Hereditarj^ Title at present (1916) held by Captain 
Desmond Fitzjohn FitzGerald, D.L., of Ghn Castle, Co. 
Limerick. His mother was Janet, daughter of Major 
Burton, and his paternal grandfather was Dr. Maurice 
FitzGerald, a surgeon in the East India Company's Service. 

Educated at home, young Charlie FitzGerald — as his 
medical friends in after-years were wont to call him — in 
due time entered Trinity College, Dubhn. At the Whiter 
Commencements of 1864 he graduated in Arts. Four 
years later he took the degrees of Bachelor of Medicine 
and Master of Surgery in the University of Dubhn, pro- 
ceeding to the M.D. degree in Michaelmas Term of 1873, 
when he became a member of the Senatus Academicus. 

Shortly after he graduated in Medicine and Surgery in 
1868, Dr. FitzGerald went to Paris mth the object of 
studying diseases of the eye mider Professor Xavier 
Gdlezowski, at that time at the zenith of his fame as an 
ophthalmologist. On his return to Dubhn he commenced 



M Mrmonam. 



practice in ophthalmic and aural surgery. His first 
appointment was in connection with the South Dubhn 
Union Workhouse, in the infirmary of which he took charge 
of eye cases. He was soon appointed Assistant Surgeon to 
the National Eye and Ear Infirmary, Dublin, to which 
institution he afterwards became fiill Surgeon. 

FitzGerald quickly advanced to the first rank in his 
!>p3cialty, and his consulting and ordinary practice 
t ccupied nearly all his time. In 1873 he was appointed 
Ophthalmic and Aural Surgeon to the House of Industry 
Hospitals, as they are called. This post he resigned in 
1883, when he became Consulting Ophthalmic Surgeon to 
the Richmond Hospital — the Surgical Hospital of the 
House of Industry group. The medical school of these 
hospitals was the Carmichael School of Medicine, after- 
wards called the Carmichael College of Medicine in its new 
premises in Aungier Street, Dubhn. In 1873 Dr. Fitz- 
Gerald was appointed Lecturer on Ophthalmic Surgery 
in the Carmichael School. Sixteen years later, when it was 
amalgamated with the School of the Roj^al College of 
Surgeons in Ireland in the j^ear 1889, he became Professor 
of the same subject, but, as it were, " without p^rtfoho," 
as no course of lectures in ophthalmology is included in 
the curriculum of the Conjoint Scheme of the Irish Royal 
Colleges. 

In 1876 Dr. FitzGerald was appointed Honorai-y 
Surgeon-Oculist-in-Ordinary to Her Majesty Queen 
Victoria. This appointment was subsequently continued 
through the reigns of King Edward VII. and King 
George V. 

When the National Eye and Ear Infirmary and St. 
Mark's Ophthahnic Hospital were merged in the Ri)yal 
Vict<rria Eye and Ear Hospital, Adelaide Road, Dublin, 
FitzGerald became one of the Surgeons to the Hospital. 
But from the active duties of this post ho retired some 
years ago. 

In 1884 Dr. FitzGerald became a Licentiate of the 
Royal College of Physicians of Ireland, proceeding to the 
Mem1)ership in the following year, and being elected a 
Fellow in 1880. On St. I^uke's D.iv. 1912, ho was luiani- 



in iilcmoriam. 



mously chosen President of the College. It was the first 
occasion on which an oplithalmologist was called to the 
Presidential Chair of the College of Physicians — an 
incident in the historj' of the College to which the President 
made a graceful allusion in returning thanks to the Fellows 
for the honour done to him. On vacating his high office 
on St. Luke's Day, 1914, the President presented to the 
College an enamelled medallion badge bearing the 
Collegiate Arms in further recognition of his appreciation 
of the compliment paid to his specialty. 

Dr. FitzGerald was not a frequent or a prolific Avriter, 
but his occasional communications to the medical journals 
were of sterling merit. In 1871 he pubhshed in the 
British Medical Journal a paper on '" Visible Pulsation of 
the Arteria Centralis Retinaj in Incompetency of the 
Aortic Valves." To the Irish Hospital Gazette, July 15, 
1873, he communicated a case of "" Congenital Nyctalopia," 
commonl}' termed " Hemeralopia," which he had pre- 
viously reported to the then recently founded DubUn 
Biological Club — now so well known in Irish medical 
circles. For the same medical publication, which had a 
brief though briUiant career under the able Editorship of 
Dr. (afterwards Sir George) Duffey, Dr. FitzGerald 
wrote many important reviews of works on Eye and Ear 
Diseases. Before the Medical Society of the College of 
Physicians, on May 13, 1874, he read a paper on '" The 
Ophthalmoscopic Appearances of the Optic Nerve in Cases 
of Cerebral Tumour." This valuable and learned com- 
mrmication was pubhshed in the number of this Journal 
for June, 1874 (Vol. LVIL, No. 30, New Series, page 538). 
It is illustrated with a beautiful coloured plate, showing 
the condition knowii as " Stauungs -Papilla " or " Choked 
Disc." 

So far as to FitzGerald 's pubhc and professional hfe. 
The writer of this Memoir was privileged to enjoy an 
intimate acquaintanceship and fast friendship with him 
for well-nigh half a century. In the autumn and \\-inter 
of 1867 we served together as Resident Pupils in Sir 
Patrick Dun's Hospital. Some fifteen years later — in 
1882 — he joined a small " Medical Dinner Club," founded 



$tt iHcmomm* 



in 1875, and of which the writer was an original member. 
Through all the years which followed, FitzGerald held his 
fellow-members captive with the silken cord of a loving and 
guileless friendship. He was indeed a brother among 
brethren, who mourn him to-day as though that precious 
name stood for relationship by birth as well as by adoption. 

Mention has been made above of FitzGerald's last 
resting place, St. Fintan's Churchyard, at Sutton, Howth. 
To the Hill of Howth — that bold headland which forms 
the north-eastern boundary of the beautiful Bay of 
Dublin — Y\e was devotedly attached. Some years ago, 
his friend, Mr. George Prescott, planned a bungalow for 
him near the Baily Lighthouse. To it FitzGerald gave 
the name of Shanet, and there he spent his summer holi- 
days year by year. He left his charming country home 
only a few hours before his death. Both there and when 
resident in Dubhn, he devoted his leisure to the cultiv^ation 
of an inborn musical taste and to art. 

Dr. FitzGerald was twee married — first in 1869, to 
Isabel Ferrier, daughter of the late Peter Roe Clarke, of 
Dubhn. She died in 1877, leaving four sons. The eldest, 
Francis, is an electro -chemical engineer, resident at 
Niagara Falls, U.S.A. The second son, Charles, is a 
journalist, also living in the United States. James, the 
third son, is a musician. He was formerly Organist and 
Choir Master in Christ Church Cathedral, Dubhn. He is 
at present on active service in the Army Service Corps, in 
which branch of His Majesty's Forces the fourth and 
youngest son. Captain Edward FitzGerald, is also noAv 
serving his King and Country in the Great War. 

On February 22, 1908, Dr. FitzGerald married, en 
secondes noces, Edythe, daughter of John and Juha 
Overend. To that devoted wife and mourning Avidow the 
words of Cowper may fitly be addressed — 

" The path of sorrow, and that path alone, 
Leads to the land where sorrow is unknown." 



J. w. r>T. 



THE DUBLIN JOURNAL 



OF 



I 



MEDICAL SCIENCE. 

AUGUST 1, 1916. 

PART I. 
ORIGIN'AL COMMUNICATIONS. 



Art. IV. — Fractures niul Fracfnrv Difilocatio^fi.^ By 
John S. M'Ardle, M.Ch. {Hon. Causa) Jl.U.J., 
F.R.U.I., F.R.C.S.T.; Professor of Surgery, National 
University of Ireland; Senior Surgeon, St. Vincent's 
Hospital; Consulting Surgeon, National Hospital, 
Holies Street, and Children's Hospital, Temple Street, 
Dublin. (Illustrated.) 

(Cnnfluiird jrow Vnhinir CXTJ.. pfi(ic .S23.) 

FRACTrBR OF Clavicle. 

Fig. 1 rejiresents the rubber ]ilaster molhod of Sayer. 
In the hunting field or on the racecourse this is the usual 
method of treatment. Eveiy text-book of surgery de- 
scribes the method of its apjilication, and so I need but 
tell you that it is safe and comfortable. On the other 
hand, when available, T ])refer using KUis's Crutch, as it 

• A Course of Lectures on Clinical Surgery delivered at St. Vincent's 
Hospital, Dublin. 

VOL. CXLII. — NO. 536, THIRD SERIES. F 



74 



Fractures and Fracture Dislocations. 



is called. Fig. 2 shows how it supports the shoulder. 
Before applying this apimratus, the axilla should he well 




Fig. 1. 
Saver's Method. 



dusted with chalk, starch, or horic acid powder, and every 
few days tlie crutch should he lowered, the parts sponged 




Fig. 2. 

I'illis'f; Cfutcli. 

witli spirit of camplior, dried and re-powdered ; by this 
means the patient is sax'ed from very unpleasant der- 
matitis. 



Mk. John S. M'Aedle. — Fractures cukJ Frdctiirc Dislocations. 





P-i 







1 3 e c^ £ 







Mr. John S. ^V Audle^—F racl in( s and Fruclnrc lUsh)rtitio}ifi. 

PLATK II. 




Fio. 7. 




Fig. 9. 



By Mr. John S. M'Ardle. 



75 



Pray reinemher that dnrin;^ this dressing the shoulder 
must be fully supported by the surgeon, so that the proper 
bone-line may be maintained. 

Fractures at the upper end of the humerus are the next 
to engage our attention. Unless taken in hands im- 
mediately these fractures, especially in the young, lead 
to unfavourable results. Any displacement of the frag- 
ments is followed by much callus formation, with sub- 
sequent limitation of movement. If extension of the limb 
is carried out from the beginning, passive motion at the 
shoulder may be started after ten days, the splint being 
replaced after each seance. Many of the cases of per- 




FiG. 4. 



manent stiffness we come across would have been avoided 
if this method of treatment had been adopted. 

The ;r-ray which I now show you (Plate I., Fig. 3) was 
taken five weeks after the accident ; and as the upper end 
of the lower fragment pressed upwards to the edge of the 
glenoid, limitation of movement was very marked. This 
would have been a very easy case to deal with by splints if 
seen early, but it was quite impossible to bring the parts 
into line without an open operation. A vertical incision 
along the bicipital groove enabled me to put a plate on 
the outer side of the bone, and this secured satisfactory 
luiion, In all cases of this class the splint shown at 



76 Fractures and Fracture Dislocatiovs. 

Fig. 4 is perfectly satisfactory. When this is not avail- 
able, a long external L-shaped splint, to which an axillary 
lac can be applied, gives a very good result. Two holes 
at the upper end of the splint allow the fixation of the lac. 

\A"hen the fracture through the anatomical neck occurs, 
and especially if the head (as it often does) passes into the 
axilla, open operation is the proper treatment ; and the 
sooner this procedure is carried out the better. There is 
no use in toying with this trouble through a straight in- 
cision, as in resection of the joint. I have known hours to 
be spent in efforts at reduction of this fracture, and often 
they have been unavailing. 

A curved incision from the tip of the coracoid to the 
tubercle of the acromion convex downwards enables one 
to raise a flap of the deltoid, then cut the capsule of the 





Fm. .'). 
l\rcArdle's tnotliod bono tractor. 

joint nlong the insertion of the sujira-siunatus, thus avoid.- 
ing the tendon of the biceps. The circumflex nerve is far 
below this line of incision, so that we preserve the useful- 
ness of the deltoid muscle, which is carefully sutured after 
the capsule has been restored. The free opening of the 
joint allows easy mani])ulation of the head of the bone. 

In bringing the u])|)er fragment into place, powerful 
hoolxs (such as ihe one liere shown in Fig. 5) are of great 
service. Once in |)lnc(> " Tjpmbolt's p)ono " forceps fixes 
it wliile two naiis ai<" diivi'n through llic head into the 
shaft. The head of t lie nails should \>r incsscd throngli the 
cartilage by a punch. Once the head of the nail goes well 
into the bone, the cartilage closes over the metal, and heal- 
ing is almost innncdiate. 

Tn this operation screws are not as handy as nails, and 
rnv .screws and driver are of no use whatever. 



Mr. John S. ^NI'Ardle. — Fractures and Fracture Dislocations. 

PLATE TTT. 




Fi(.. 11. 




I'Kl. VI. 



^\n. John S. ^^IAudlf,. — Fnictiircs (Uid Frdcliirc Dislocations. 

PLATE LV. 




Fid. 13. 




Fig. 14. 



By Mr. John S. M'Ardle. 



77 



Early passive motion is necessary, but massage should 
not be carried out, especially in the young, as it leads to 
profuse callus formation. 

All fractures implicating the upper end of the humerus, 
such as tearing off of the tuberosities (Plate I., Fig. (3), 
cause persistent pain about the insertion of the deltoid 




owing to implication of the musculo-spiral nerve. No 
application to the site of reflected pain is of any use. 
Lead and opium lotion over the entire shoulder offers the 
Ijest chance of relief once the bones are in proi)er position. 
Separation of the tuberosities, such as the one here 
depicted, are due to muscular action, the powerful supra- 
and infra-spinatus muscles being chiefly responsible. 
In these cases there is no shortening of the arm, and so 
there is no need of extension in putting up these fractures. 



78 Fracturca and Fracture Dislocalioits. 

Stroineyer's cushion to support the arm and abduct it and 
a strip of 4-inch zinc rubber plaster from the front to the 
back of the chest across the point of the shoulder bind 
down the upper fragment. 

In these cases the pain is rarely complained of at the 
site of injury. x\s a rule, it is reflected down the outer 
side of the arm. 

For fracture about the middle of the humerus (Plate 
II., Fig. 7) there is no splint that one can easily im- 
provise, so comfortable and so reliable, as that employed 
by my colleague, Mr. Tobin. Fig. 8 shows how a sheet 
of poro-plastic may be cut so as to secure extension as 
well as fixation of the bones. 



Fig. 10. 

When the bones are broken above the elbow-joint (as in 
Plate II., Fig. 9) the anterior gutter splint, poro-plastic 
or metal (the latter for choice) acts admirably, and en- 
ables oue to frequently examine the limb from behind, 
j'ig. 10 shows a well-shaped splint of this kind. 

Fractures of the humerus extending into the elbow-joint 
are often very complicated, and in the adult they should 
always be dealt with by open operation, unless an .r-ray 
examination shows that the fragments can be seciu'ely 
maintained in accurate position by a splint. 

Ill ni;iny cases (as Plate 111., P'ig. II, shows) it would 
be utteily Jnj|)ossible to scciuc approximation of the frag- 
jnents l)y |)alliative means. "^^riie result of ])eriosteal 
suture is demonstrated in Plate 111., Fig. 12. The child 
has now a pcMfectly useful arm. 

In riatc IV., i^'ig. \'.\, a, Y-«'':i|'i''' liiiftinc thiough the 
trochlea, with inward and backward displacement of the 



^[h. John S. M'Ardle. — Fnictures and Fracture Dislocations. 

PLATE V. 




Fig. l.j. 




iMi.. m. 



Mh. Jf)HN S. M'Ardle. — Fnictitrcs and l-l-actiirr l)is1(K(itio}is. 



PLATE VI. 




Fig. 1' 



Clinical Hcport of the llolnndd IIo,si)itiil. 79 

inner fragment, could uot be reduced unless l)y opt^nitidn. 
This was easy of accomplishment. 

Plate IV., Fig. 14, is an example of a type of frac- 
ture which 1 find rather common. Any of these 1 have 
come across after treatment by splints have shown very 
poor results, and I have been obliged to open several to 
remove redundant callus which wt\s fixing the joints. 

The next (Plate V., Fig. 15) shows the effect of a 
single plate fixed on the posterior surface of the humerus. 
The patient left the Private Hospital on the tenth day, 
and now his arm is as good as the other. 

The next picture illustrates a very grave case, the result 
of an accident in the hunting field. The sporting master 
of the most sporting pack of foxhounds in Ireland came a 
cropper over barbed wire, and falling dii-ectly on his elbow 
sustained the fracture depicted at Plate V., Fig. 16. 

Now, this case would be a complete failure under any 
treatment other than that which I adopted. 

As soon as shock had been relieved, and the great effusion 
in and round the joint subsided, I made an incision convex 
downwards, thus exposing thoroughly the entire elbows- 
joint. This enabled me to pass a long screw (as seen in 
Plate VI., Fig. 17) through the radial head of humerus 
and trochlea. Then a Y-shaped plate was fixed witli one 
screw into the shaft and one into each condyle. Six 
weeks after operation the patient w'as riding about, with 
a very useful, though not quite perfect, arm. 

Art. V. — Clinical Report of the Rotunda Hospital for 
One Year, November 1st, 1914, to October 31st, 1915. ^ 
By the Acting Masters, namely, Sir William J. Smyly, 
M.D., F.R.C.P.I. ; Richard'^ D. Purefoy, M.D., 
F.R.C.S.I. ; and E. Hastings Tweedy, F.R.C.P.I. 

(Conti)iued jrom ixigc ^6.) 

The following cases of special interest may be briefly 
referred to here : — 
Case I. — A. M., aged thirty-three, third pregnancy. Ad- 

* Read before the Section of Obstetrics in the Royal Academy of 
Medicine in Ireland on Friday, May 19 ,1916. 



80 Clinical Report of the Rotunda Hospital. 

mitted 24th with oedema of legs, feet and face, intense head- 
ache, dimness of vision, and vomiting, scanty urine ; albumen 
and casts present. Slight improvement on water diet till 31st. 
At 6 p.m. patient complained of severe pain in abdomen, 
followed in two hours by slight external haemorrhage. Vagina 
plugged, uterus being very tense, tender, and increased 
slightl}^ in size, with pulse 160 and very feeble. Tlie diagnosis 
of concealed haemorrhage was obvious, and Csesarean section 
was performed. A large amount of free blood was found in the 
abdominal cavity and also in the uterus. The intraperitoneal 
haemorrhage evidently came from the vessels of the left broad 
ligament, and ceased after the left ovarian vessels were tied. 
Convalescence normal. 

Case II.^ — A. L., aged twenty-four, first pregnancy ; a very 
neurotic, hysterical woman. Admitted January 13th, 1915, with 
persistent vomiting, inability to walk, reflexes lost, constipa- 
tion, passing small amount of urine ; great emaciation. Treated 
with sodium bicarb, per rectum and a small quantity of water 
by the mouth. Vomiting ceased in three days, and patient was 
discharged on the 2nd of February. Re-admitted on March 
10th with the same symptoms, but vomit " coffee grounds " 
in character. Stomach lavage large, and frequent enemata 
were not even coloured by faeces. Vomiting continued. O^ving 
to patient's critical condition Caesarean section decided on 
instead of induction of labour. Vomiting ceased after 
operation, and condition improved. Cliild, eight weeks 
premature, died on the 5th day. Patient discharged well on 
March 30th. 

Case III. — A. D., aged twenty-nine, first pregnancy. 
October 2nd : admitted comatose, having had two tits before 
admission. Patient's whole body swollen, secreting practically 
no urine, which was almost solid with albumen ; blood pressure 
242. Treated with mor])hine; stomach and bowel lavage ; pur- 
ges left in ; sodium bicarb, per rectum, three hourly; poultices 
to loins. Patient had six very severe tits in hospital. Abdomen 
very large and very tense ; palpation was impossible ; patient 
very restless, and obviously in labour. Head was noticed on 
perineum, and rapid delivery was decided on. Forceps applied, 
small child extracted ; 2nd bag of membrane aj)peared im- 
mediately at vulva, and was ruptured artiticially ; 2nd child 



f 



By Sir W. Smyly, Drs. Purefoy and Tweedy. 81 



I: 
I 






Remariis 


Maternal death, due to pernicious 
anajmia 

One brow converted to vertex 

Two attempts at forceps failed 

before admission 
Chronic alcoholism 

Triplets 


2 
o 


13 

> 

<5 


,M ., ^ „ ^ - ^ ^ 1 - 


-H -)< -5^ — ] 1 "^ 1 — (>q 


1 



"3 
S 

P3 


73 


1 - - i 1 1 1 1 I 1 


1 

t» 


V 

P3 




Number 

of 

Cases 




s 

"■S 

eS 
c 

'i 




Prolonged Krst stage 
Delay in second stage 

„ P.O.P. 
Contracted pelvis 
Face converted to vertex 
Secondary inertia 
Prolapse of cord - 
Placenta proevia 
Heart disease 
Eclampsia 



82 



Clinical Report of the Rotunda Hospital. 



was extracted later with forceps. Third bag of membranes 
presented at vulva, ruptured artificially ; child presented by 
shoulder ; internal version performed with ease, and child 

Tabi,e X. A. — Number of Pregnancy of Patients in whom tlie 
Forceps was applied. 



Para 


Number of 
Forceps Cases. 


I. - - - 

II. 

III. 

IV. - 

V. and over 

Total 


74 . 
9 
4 
2 

7 


96 



delivered as breech. Patient had the last fit whilst perineum 
was being stitched at 6 30, and was conscious next morning. 
Normal convalescence, and was discharged on October 13th. 
First baby died on 5th day, other two doing well. 

Iable X. H. — Af/es of Patients in whom, the Forceps was 
applie<L 



Age 


Number of 
Forceps Gases. 


17-25 
26-30 
31-35 

36 aud over - 
Total 


31 
39 
19 

7 


96 



Case IV. — Rupture of Right Horn of a Two-Horned Uterus. 
At 8 a.m., January 20th, 1915, having been in perfect health, 
she was suddenly seized with violent pain in the region of 
the umbilicus, and fainted ; after a time she recovered con- 



]\\ Sii; W. Smvia, Drs. Turkfov and Tweedy. 83 

sciousucss, but soon fainted again, and spent the day going 
from one fainting fit into another, until in the evening Dr. 
Winder was called in. and sent her to tlie Rotunda. On 
admission she was blanched and pulseless, and there could be 
no doubt as to the diagnosis of ruptured ectopic pregnanc3^ 
When the abdomen was opened it was found filled with blood. 
Tlie uterus was bicornate, and the right horn had ruptured 
and a four months' foetus had escaped into the abdominal 
ca\dty ; the placenta was protruding through the hole in 
the uterus. Tlie injured horn and the foetus were removed, 
but OA^nng to the condition of the patient no attempt was made 
to remove the extra vasated blood. The patient made a normal 
recovery. 

Case V.— M. R., aged forty-five, 7-para. She was sent to 
hospital by Dr. Murray of Roscrea, having been upwards of 
twenty-four hours in labour, and arrived at 5 a.m. on the 6th of 
January, 1915. On examination it was found that the foetal 
head was freely movable above the peh4c brim, and no foetal 
heart could be heard. On vaginal examination the pelvis was 
found to be blocked by a large solid tumour, and the foetal 
head could be reached with the greatest difficulty. Tlie child 
was dead, the membranes had rux)tured maii}^ hours before, 
and the patient had been examined before admission by three 
different people : her condition as regarded asepsis was un- 
certain. Tlie tumour could not be pushed upwards. There was 
not room to perforate nor to deliver by version or forceps. It was 
determined to give scopolamine-morphine and to give Nature a 
further chance, but as there Avas no alteration in her condition 
after five hours it was decided to perforin Csesarean section 
and to remove the uterus and tumour. Th walls of the uterus 
were found to be enormously thick and the lower segment to be 
very thin. The tumour, Avhicli was a myoma as large as a 
foetal head, was enucleated from the triangular space bounded 
in front by the cervix and vagina beliind by the rectum, 
and above by the peritoneinii of Douglas' pouch. 



84 Clinical Report of the Rotunda Hospital. 



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86 



Clinica] Report of the Bofiuida Hospital. 



Table XII. — Morhiditij — B. M. A. Stamlard. 





Nov. 
Dec. 
Jan. 

Feb. 








"-5 >^ •< CC 


O 


1 

3 

o 


Total Deliveries 


140 


149 


161 


162 


176 


165 


196 


179 205 


181 


189 


1 

167 2070 


Cases Morbid - 


7 


1 


5 


9 4 


6 


6 


7 


9 


9 


14 


11 88 


Percentage 


.5 


.68 


3.10 


5.55 2.29 


3.36 


3.06 


3.91 


4.39 


4.97 


7.35 


6.52 4.25 




Total number of morbid cases - 88 






Total percentage morbidity - 4.25 






Total average morbidity - 1 in 23.52 





Table XII. A. 
Comparison of MorMdity in Primiparce and Mnltiparce. 

PKIMIPAR.*;. 





> 

o 
'A 


c5 

Q 


i i 

►-3 1^ 


1 
3 


■■a >. s .& M 

ft ca 3 3 3 
< ^ ^ \ '^ < 


1 


O 


"3 
o 


Total deliver- 


43 


65 


56 44 


6S 


n 


77 


76 


90 65 


76 


59 791 


ies 
Cases Morbid 


4 


1 


2 


3 


2 


3 


3 


4 


8 4 


11 


6 51 


Percentage - 


9.30 


1.53 


3.57 


6.81 


2.89 


4.22 


3.89 


5.26 


8.88 6.15 


14.47 


11.67 6.44 


MULTIPARiE. 


Total deliver- 


97 


84 


105 


118 


107| 


94 


119 


103 


115 


116 


113 


108 


1279 


ies 
Cases Morbid - 


3 


— 


3 





1 

2; 


3 


3 


3 


1 


5 


3 


fi 


37 


Percentage - 


3.09 


— 


2.85 


5.09 


1.86 


3.19 


2.52 


2.91 


.86 


4.31 


2.65 


4.62 


2.88 



Sixloen extra-genital caiisos of mothidity were classified 
as lollovvs : — Mastitis G, |>lithisis '2, iluMiinatism I, intts- 
lin;il ixMloiiitioii I, (('lliilitis of hand I, iii(liienza-])neii- 
iiioiiia "2, intliien/!! 1, phlcyiiiasiti allin ddlciis I, eoiistij)a- 
(ioii 1. 'iVital 10. 



By Stf W. Smylv, Drr. Purekoy and Tweedy. 87 



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88 Clinical Report of the Rotunda Hospital. 



Tablk Xli. C. — Dnraiion of Stay in Hoapifnl, after delivery, 
of Morbid Cases. 



Under 10 days • - 34 cases, including 1 death 

10-19 „ - 36 ,, „ death 

20-29 „ - - 13 „ .,1 dealh 

Over 29 „ - - 3 „ „ 3 deaths 



Total . . 86 5 deaths 



Tablk XII. 


D. 


— Dm 


ation of 


Feb 


rile 


Temperature. 


Under 5 days 
5-9 „ 
10-19 „ 
Over 19 „ 


- 


• 


57 cases, 
Ifi „ 
8 ., 

•'"> ,. 

8f. ., 


including death 
1 death 
,, 1 death 
„ 3 deaths 

,, r> deaths 


Total 



Tablk XII. E. — Highest Tewperalure Recorded. 



F 100°-100.9° - - 27 cases, including death 

101°-101.9° - - 22 „ „ (t death 

102°-102.9° - • IS „ ,, (t death 

103°-103.9'' - - 8 „ „ 1 death 

104° and over - - U ,. ,, 4 deaths 



Total - - 8(i „ „ 5 deaths 



Tabi.k XII. F. — '/reahiieiif, of Morbid Cases of Genital Origin. 



Utero-vaginal douches - - - - 13 patients 

Administration of vaccine - ■ 7 ,, 

Adniinistriilioii of vjioiano and scrum ■ • 3 ,, 

Kxploration of uterus - - - - 2 „ 



By Sir \V. Smvlv, 1)rs. Pirefoy and Twerdv. 89 

Taui.e XIII. — Nature of Inject iou and of Vaccine in Cases vliere 
Vaccine was used. 



No 










of 


Infection 


Vaccine Used 


Results 


Remarks 


Cases 










6 


Streptororcns 


Rotunda Stock 


2 deaths 


One from acute sepsis 
One from acute 
P3'a9mia 


2 


Streptococcus 


Rotunda Stock and 


1 death 


Tuberculosis, intes- 




and B. roli 


autogenous 




tines and kidneys 


1 


Sirepto. and 
Staph. 


Stock and autogenous - 


1 death 


Septicaemia 



Table XIV. — Number of Injections of Vaccine in each Patient. 



No. 

of 

Injections 



No. 

of 

Cases 



Results 



Remarks 



1 




1 death 


Pernicious anaemia and abscess of lui 


2 




— 


— 


3 


2 


1 death 


Acute sepsis 


4 




— 


— 


6 

7 
8 




1 death 


Tuberculosis, intestine and kidney 




1 death 


Septicaamia 


9 

10 

and over 




1 death 


Pyaemia 



90 



Ciinical Report of the Rotu7ida Hospital. 



y. 



a 


See Table VII. 

First, twins, dead ; 2nd, forceps, dead ; 
3rd, 7 months ; 4th, normal, alive ; 
5th, forceps, dead ; 6th, abortion ; 
7th, spontaneous in Walcher's 
position. Now 37 weeks ; left 12 
hours ; 2 doses scopolamine 
morphia ; natural delivery 6 hours 
after pubiotomy ; child had gutter- 
shaped depression on left parietal 

Prophjdactic pubiotomy done 19 days 
before delivery, Oct. 23, 1914; 1st 
child perforated ; incision over pubic 
bone ; peritoneal cavity opened, 
bladder pushed aside, and bone 
divided by Gigli saw ; child presented 
breech ; cephalic version by external 
manipulation ; head delayed at brim, 
but delivered by natural efforts 


Result ] Result 

to to 
Mother \ Child 


Breech — Alive 
Vertex — Dead 

Alive 


1 
< 


'-S 
eS 
o 

l-H 


Contracted 
pelvis 


Nature 

of 

Operation 


Bumm's 
subcutaneous 

55 

Doderleins 


Para Date 


-* 


-.2 


< 


S S 55 


1 





P.Y Rtt^ W. Smyly. Drs. P[T.kk()v and Twrrdy 



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Clinical Report of the Rotunda Hoapital. 



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Statistics of the Gynecological Department. 
Table I. — Number of Admissions and of Operations. 



Number of Admissions 






604 


,, Operations • 




- 


539 


Tablk II. — Nature and Number of Operations. 


Abdominal Section 


1 
222 \ 


Uterus— Curettage— cow. 








Interposition 


3 






Vaginal shortening of 




Vulva and PERiNyEUM — 




utero-sacral hgaments 


2 


Excision of vulva for 








carcinoma 


2 


Myomectomy — 




Excision of condylomata - 


1 


Abdominal 


11 


Excision of papilloma vulvae 


1 


Vaginal - 


3 


Removal of Bartholin's 




Hysterotomy 


3 


cyst 


4 






' Perinaeorrhaphy— 




Hysterectomy— 




1 Complete 


7 


Supra-vaginal 


20 


Incomplete 


69 


Complete - 


5 






\Vertheim 


11 


Vagina— 




Vaginal - 


1 


Anterior coliwrrhaphy - 


U 


Caesarean section - 


14 


Vesieo-vaginal fistula 


2 






Posterior lolpotomy 


2 


Tubes and Ovaries— 




Excision of vaginal cyst - 


2 


Salpingectomy— 




Plastic for vaginismus 


1 


Single - 


13 






Double - 


6 


Rectum^ — 




Salpingo-oophorectoniy \ 


ith 


Rectal fistula 


1 


other oi)eratiou8— 




Haemorrhoids 


1 


Single - 


11 






Double - 


8 


Cervix— 




Salpingostomy 


11 


Trachelorrhaphj- • 


37 


Ectopic pregnancy 


7 


! Amputation 


30 


Resection of ovary 


14 


Posterior division 


22 


Ovariotomy 


22 






Removal i^arovarian cyst 1 


Uterus — 




Sterilisation 


1 


Curettage — 








Alone - 


125 


Miscellaneous — 




Combined with other 




Appendicectomy associated 


operations - 


148 


with other operations 


o 


Polypus (benign) 


1 


Resection of intestine 


2 


Ventral suspension — 




Laparotomy for acute 


Alone - 


1.5 


general peritonitis 


2 


Combined with other 




Laparotomy for drainage 


operations 


92 


of pelvic abscess 


2 


Gilliam's ventral suspension 


3 


Laparotomj' for ligature of 


Alexander- Adams 


7 


ovarian veins - 


I 


Sir William Sinclair's ab- 




Plastic operation for ven- 


dominal suspension 


1 


tral hernia 


6 


Ventral fixation - 


1 


Talma-Morison 


1 


Vaginal suspension 


5 


Excision of cyst of broad 


Vaginal fixation - 


4 


ligament 


1 



94 diagnosis in Uveitis. 

Art. VI. — Diaynosis tn Uveitis.''^ By Euphan Maxwell, 
M.B. Univ. Dubl.; F.K.C.S.l. ; Assistant Surgeon, 
Koyal Victoria Eye and Ear Hospital, Dublin. 

First Part. 

I PRorosE to divide this lecture into two parts. In the 
first I will briefly survey such methods of diagnosis em- 
ployed in clinical and scientific investigations on inflam- 
mations of the uveal tract as I have been able to find in 
the literature ; in the second part, I will deal with my own 
work on the subject during the past year. 

Before commencing this survey of Uie diagnostic pro- 
cedures, it will be as well to give a classification of the 
varieties of uveitis. 

The classification I have adopted is — with some addi- 
tions — that of de Schweinitz, as stated at the Inter- 
national Congress of Medicine in 1913 (85). He states 
that infection may be ex- or endogenous, that it may be 
bacterial or toxic. 

Endogenous infections may be classified as due to certain 
groups of diseases. 

1. Constitutional diseases or disorders of metabolism — as 
gout, rheumatism, diabetes. 

•J. Specific infectious diseases — as tuberculosis, syphilis, 
gonorrhoea, influenza. 

3. Blood diseases — as ana?mia. 

i. Kenal disorders and anomalies of urinary secretion — 
as nephritis, lipiemia, oxaluria. 

5. Auto-intoxications — as in intestinal disorders, 
menstrual disturbances, detachment of the retina (17). 

G. Local diseases and infections — as in the rhino- 
pharynx, tonsils, teeth, accessory sinuses, skin, &c. 

7. Sympathetic ophthalmia. 

With this classification as a guide, we may now consider 
the various diagnostic measures tiiat might be adopted in 

* Mary Louisa Prentice Montgomery Lecture, delivered in tlie Bchool 
of Pliysic ill Ireland, on Friday, June '2:i, I'.Mti. 



By i3R. Kui'HAN Maxwell. 95 

any ifiveri case. The order in which these measures are 
considered has, of course, no bearing on their merits. 

The first one I am mentioning is that in which we try to 
gain information as to the cause of the uveitis from the 
clinical signs and symptoms of the patient. 

The appearances and course of the disease in the eye 
itself are rarely of much diagnostic value, indicating as 
they do the severity of the attack, but not its cause. Ex- 
ceptions to this are the condylomata and yellowish-grey 
nodules, which are at times present in uveal tracts affected 
by syphilis, or tuberculosis respectively. Their presence 
aids a diagnosis ; their absence is valueless. 

Possibly, also, w^e may take as an exception the well- 
known clinical course of sympathetic ophthahnia, which, 
although it gives us no clue as to the causal agent, enables 
us to diagnosticate the condition. 

On the other hand, an accurate observation of any clini- 
cal features which the patient presents elsewhere in his 
body is of the greatest diagnostic value. If a patient with 
chronic empyema of the antrum of Highmore develops 
uveitis, the evidence is strongly in favour of the latter being 
due to the causal organism of the empyenui, which evi- 
dence is corroborated if the cure of the antrmn disease stays 
the course of the uveal inflammation. 

The second diagnostic measure to be considered is that 
in which the cause of the inflammation is sought locally — 
either histologically or bacteriologically, in uveal tissues or 
aqueous humour. 

As regards an examination of the tissues, sections of an 
excised piece of iris may often give valuable first-hand in- 
formation, while sections of an enucleated globe may give 
valuable presumptive evidence as to the condition of the 
other eye. 

Fuchs successfully employed the anatomical evidence 
in classifying uveitis into types (17). As a rule, however, 
it is useless as an aid to the determination of the cause, 
except when tubercles are met with in tubercular uveitis 
(28), gummata in syphilitic cases (28), or cysts in the 



96 DicKjnusis in Uveitis. 

retinal epithelium of the iris, apparently a very constant 
feature in diabetic uveitis (17), (28). 

On the other hand, the bacteriological findings in the 
tissues are of the greatest value, as they may shov^^ us an 
organism, which, if not the sole cause, is presumably one 
of the causes of the inflammation. Most of the well known 
pathogenic organisms have been found in different uveas 
("27). Besides this direct examination of the tissues much 
useful information can often be gained by their inoculation 
into animals. 

Passing now to the bacteriological examination of the 
aqueous humour, an examination much more readily per- 
formed than that of the uvea, we find that many and 
various organisms have been discovered therein. 

The negative findings, however, far outnumber the posi- 
tive ones in chronic cases, and this has been brought for- 
ward by some as an argument in favour of the theory that 
most of these cases are toxic in origin, rather than directly 
bacterial (5a), (17). Into this debatable ground, however, 
1 will not trespass. 

The third diagnostic measure, the importance of which 
in late years has been nnich brought before the notice of 
o[)hthalmologists, is a routine bacteriological examination, 
in otherwise obscure cases, of the blood, urine, faeces, and 
mucous membranes. 

The fourth is a cytological examination of the blood. 
This procedure is fre((uently carried out as a diagnostic aid 
in suspected cases of sympathetic o))hthahiiia. 

Many observers claim to have found an increase in the 
large mononuclear leucocytes in this condition; this in- 
crease they corisider is highly suggestive of the causal agent 
being a proto/.oon ((>), (U). Others, on the contrary, have 
not verified this observation (14), (28). 

The fifth diagnostic measure comprises the chemical ex- 
amination of the urine, fa'ces, and gastric contents. Such 
an examination may prove of special help in cases of uveitis 
where gastro-intestinal auto-intoxication is suspected. 
The test for indican in the urine is one which has received 



By JJr. El than Ai ax well. 97 

much [)i-uiiiiiienct' in this coiinectit)n (35). Eischnig is one 
of the wainiesl su[)[)oiters of its diaonostie value, but von 
Hii)pel and others have failed to verify his claims. 

Lender my sixth heading 1 propose to phice the numerous 
immunity reactions em[)loyed in diagnosis. We must 
remember in this connection that, in cases of disease 
})rodnced by some specific organism, this organism, 
known as antigen, calls forth a corresponding antibody. 
These antibodies form the basis of immunity. 

I propose, first, to briefly survey the methods of search 
for these antibodies in the blood, or more rarely, in the 
aqueous humour; secondly, the methods of search for 
physico-chemical changes in the blood, indicating the 
inter-action of an antigen and its specific antibody ; 
lastly, the anaphylactic reactions. 

Before commencing a review of the diagnostic measures 
in the first group, it is necessary to consider briefly the 
question of the site of formation of antibodies. A vast 
amount of work still remains to be done before this can be 
definitely answered. However, most workers in the field 
are of opinion that an infection, whether local or wide- 
spread, usually produces a general cellular activity, mainly 
in the haematopoietic organs, resulting in the formation 
of antibodies circulating freely in the blood-stream (-), 
(•20), {•I'D. Their [)resence, therefore, in the blood would 
give no information as to whether their production had 
any connection with an existing uveitis. 

At the same time it is not disputed that a certain amount 
of local |)rodiiction may occur. Conjunctival innnunity, 
for example, has been definitely proved {•!), (34a). The 
question of uveal immunity is still undetermined (34a), 
(30). 

It is quite conceivable that a local production of anti- 
bodies may take place, more especially in cases of primary 
uveitis, or of metastatic uveitis, in which the original in- 
fection had subsided. Could this be proved, the detection 
of antibodies in the aqueous humour in such cases would 
prove of the greatest diagnostic value. 



1)8 Didijiiusi.s in Uveitis. 

It must be remembered, however, in connection with 
this local detection of antibodies that, according to many 
ohservers, the healthy ciliary body allows their penetration 
from the general circulation in minute quantities. This 
permeability is greatly increased if the ciliary body be 
inflamed or in any w^ay irritated (33), (13), (26). (37), 
m), (34a, b), (8), "(2). 

It is thus obvious that in cases where antibodies have 
been detected in the aqueous humour, their presence 
should also be sought for in the blood if the diagnostic 
value of local detection is to be maintained. 

The simplest antibodies known are tlie antitoxins, 
which are capable of uniting with and thus neutralising 
their s})ecific toxins. In various kinds of theraj^eutic and 
experimental work the detection of a toxin, or conversely, 
of an anti-toxin, by this method of neutralisation is much 
employed. As an aid, however, in clinical diagnosis, it is 
not used. 

The second order, according to Ehrlich, comprises the 
agglutinins and precipitins, bodies of a more complex 
nature. Agglutinins are detected by their power of causing 
bacterial cliunping, and tests founded on this property have 
proved of the greatest aid to diagnosis, especially in cases 
of typlioid, undulant fever, bacillary dysentery, and cere- 
bro-spinal meningitis (22). Precipitins are detected by their 
|X)wer of causing precipitation of bacterial , or other foreign 
albumens, against which they have been developed. The 
method of precipitation is not employed much in clinical 
diagnosis owing to difficulties of technique. It should be 
mentioned here that it has been used in researches on sym- 
pathetic ophthalmia. If Elschnig's view be correct, that 
the broken-down uveal tissue of the first eye causes a 
toxiemia resulting in a depression of the second eye, then 
it is c<jnceival)le that antibodies are in the l)lood in cases 
of sympathetic ophthalmia, capable of ])reci])itating uveal 
albumens. The results obtained with the above test are 
not convincing however (34a), (30j. 

Thirdly, we have the amboceptors — antibodies still 



Bv Dh. Euphan Maxwell. 99 

iiioiv a)iiii)lex in tlieir action. Klulich conceives these as 
uniting on the one hand with tlie antigen ; on the other 
with conii)lement. The hitter, naturally present in the 
hlood serum, is jirohahly of the nature of a ferment, and, 
according to Bordet, thus causes digestion of the antigen 
(22). 

The presence of amboceptor can be most readily detected 
by the " tixation of complement " method, the details of 
which will be explained later. 

This method, using the suspected causal organism as 
antigen, has been employed as a diagnostic in many clinical 
diseases, with varying, but on the whole encouraging, 
results (22), (24), (32)). It has also been employed, using 
uveal emulsion as antigen, in investigations on Elschnig's 
theory of sympathetic ophthalmia. The results in this 
connection would seem to be too nnich at variance with 
one another to be of practical value (12a, b), (30), (31), 
(34a). 

According to some observers, opsonins, antibodies which 
decrease the resistance of an invader to ingestion by 
phagocytes, are to be regarded as complement and ambo- 
ceptor working together (22). The examination of the 
opsonic power of a patient's blood may be in the hands of 
skilled workers a valuable aid to diagnosis (7), (8). The 
difficulties of its technique, however, have prevented its 
more widespread application (2). 

The next antibodies for consideration are the antifer- 
ments and the protective ferments. The best known re- 
actions for their detection are those of Wassermann and 
Abderhalden. A positive " Wassermann " is due to the 
presence of what is juobably an antilipoid ferment, pro- 
duced in response to, in the great majority of cases, the 
toxic action of the syphilitic spirocha'te on the lipoids of 
the body cells. The test is also carried out by the " fixa- 
tion of com]ilement " method, and is one of the greatest 
value in determining the active presence of the Spiro- 
chaete pallida (22). 

Abderhalden 's reaction depends on the assumption that 



100 Diagnosis in Uveitis. 

])ioteins, native or otherwise to the body, but in both cases 
foreign to the blood, when introduced into the circulation 
will cause the production of specific protective ferments. 
He claims to be able to detect these in vitro by his dialy- 
sation and optical methods. 

The first is performed by placing the protein antigen 
and the suspected serum in a dialysing capsule. If the 
serum contain a specific protective ferment, the protein 
will be split up into peptones and amino-acids. These 
smaller molecules dialysing into a surrounding fluid can 
be detected by a colour reaction. 

The optical method is performed by observing the in- 
creased rotation of light taking place in a fluid in which a 
specific interaction has occurred. 

The test has been performed in, amongst other diseases, 
syphilis, tuberculosis, acute infections, and sympathetic 
o|)hthalmia. The specificity of the reaction has not been 
definitely proved m), (18), (21), (16), (5b). 

In the second group for the detection of physico-chemical 
changes in a fluid containing antigen and its specific anti- 
body, we find in addition to Abderhalden's reaction the 
following two tests : — 

The first is the so-called " epiphanin " test, elaborated 
by Weichardt. It depends on the fact that diffusion is 
accelerated if antigen and its specific antibody are brought 
together. It has proved very successful as a diagnostic in 
syphilis ('2'2). It has been em[)loyed with varying success, 
using u^eal tissue as antigen in researches on sympathetic 
(jpbtliahuia Cila). 

The second test is the "meiostagmiu" reaction, elaborated 
by Ascoli. It depends on the fact that sin face tension is 
ifihiced by the interact i(in of antigen and its specific anti- 
body. Its employment as a diagnostic would appear to have 
met with onlv varying success (-I'D, CM)). Simplification 
ol the t('('!ini()u<- of both these reactions must be looked 
loi- belorc they can be adnntted to he of piactieal diagnostic 
value. 

Finally, there are the anaphylactic reactions. These all 



By Dr. EnpHAN ISIaxwell. 101 

depend upon the fact that an individiial who has already 
been infected will, on receipt of a second similar infection, 
promptly exhibit reactive symptoms, local or general. 
These symptoms are supposed to be due, accordino lo 
Vaughan's widely accepted theory, to the rapid action of 
tlie previously })rodiiced antibodies on the foreign protein, 
resulting in its cleavage, and so liberating toxins. 

The best known of these reactions are those em|)loyed in 
the diagnosis of tuberculosis and syj)hilis. 

Among the tuberculin reactions, the sub-cutaneous test 
with general symptoms, especially a rise in temperature, 
as its positive sign, is that most generally eni[)loyed in 
ophthalmology. The intra-cutaneous test is, however, 
thought by some to be more sensitive (;22). 

In syphilis, the employment of the luetin test, carried 
out by an intra-cutaneous injection of killed spirochtptes, 
and resulting if positive in a local reaction, is of the greatest 
value in diagnosticating not only the active presence of 
syphilis, but, for some time after its cure, the fact of its 
previous existence. 

The value and number of these reactions as practical 
diagnostic measures are on the increase (22). 

Second Part. 

Having concluded this brief survey, I now pass on to an 
account of my own work on the subject during the year. 

My original intention wns to produce an artificial tiveitis 
in a rabbit's eye by an intraocular injection of a known 
bacterium, and then in due course to examine the aquecnis 
humour for the various specific antibodies. 

After a short time, however, T confined myself entirely 
to the search for amboceptor, as the "fixation of comple- 
ment " method whereby it could be detected seemed to 
present the fewest difficulties. The first series of experi- 
ments aimed at the detection of amboceptor in the aqueous 
hiunour ; the second, at discovering the presence or absence 
of its local production. 

T shall first describe the technique employed, and shall 



102 Dinrpiofiifi w Uvritift. 

then review the separate experiments. Several of these 
latter have not led to any practical result, owing to faulty 
technique. However, as I feel that useful knowledge may 
be gained by a recital of mistakes, I shall not omit them. 
The essentials of the test are as follows : — A mixture — 
containing (1) antigen, the infective agent, (2) the serum 
suspected of containing its specific amboceptor, and (3) 
complement — is allowed to stand long enough for union 
to take phice between these three elements. A second mix- 
ture — containing (1) red blood-cells, and (2) a serum cap- 
able of h.Tmolysing these cells, but from which comple- 
ment necessary to this process has been abstracted — is then 
added. If the specific amboceptor be present in the first 
mixture, its union with the only available complement 
present makes hcTmolysis of the blood-cells impossible ; if 
absent, the complement is left free to unite with the second 
serum, and hsemolysis does take place. 

My technique, which had to be improved from time to 
time, may best be considered in its latest developments 
under the following headings : — 

1, Preparation and dosage of bacteria to be injected. As 
a fresh culture of organisms is likely to j^roduce a greater 
quantity of antibodies than a long-standing one, the former 
was used where possible (22). An over-night agar or 
serum slojie of the organism, emulsified in normal saline, 
was well shaken to break up large clunqis. The emulsion 
was then snl)jected to 00° C. for an hour. This latter treat- 
ment will kill most organisms, thus reducing considerably 
such reaction as would follow their injection. At the same 
time, however, it does not entirely remove Iheir power of 
stimulating the production of antibodies. 

The dosage was gradually increased in subsequent injec- 
tions by diminishing the heat to which the emulsion was 
subjected. I'he amount of diminution depended on the 
reaction which had followed the preceding injection. 

Antibodies were usually sought for within a fortnight 
of the last of two to four injections, given at intervals of 



By Dr. Euphan Maxwell. 103 

about a week. The same plan was followed whether the 
injections were given intra-ocnlarly or intra-venously. 

2. The method of injection. — In intra-ocular injections 
the needle was ]iassed obliquely forwards and inwards 
through the conjunctiva, sclera, and ciliary body, and the 
contents of the syringe were then evacuated. This oper- 
ation was always performed under general ana'sthesia. 
If a conjunctivitis supervened, the eye was treated daily 
with argyrol. 

If the intention was to give not a local but a general 
infection, the intravenous route was chosen as given the 
speediest results i'2'1). The animal was placed in an in- 
cubator at 87° C for a few minutes, which caused consider- 
able enlargement of the superficial veins. The hair over 
the marginal vein of one of the ears was then rapidly re- 
moved with sodium sulphide solution, and into this vessel 
the injection was readily made. This operation, causing 
practically no discomfort, required no ana:>thesia. 

3. The withdrawal and preparation of fluids for examina- 
tion. — The aqueous humour was always withdrawn under 
general anaesthesia. The needle of the syringe was in- 
serted into the anterior chamber through a fairly central 
portion of the cornea. This insertion, by avoiding what in 
these cases often became a vascular limbus, and also by 
lessening the risk of bruising the iris, tended to prevent 
blood becoming mixed with the aqueous. The position of 
the needle increased the risk of producing cataract, but in 
these experiments the occurrence of such did not signify. 
The amount withdrawn varied, according to the condition 
of the eye, from 0.01 to 0.2 ccs. In most of the samjiles 
obtained, a clot formed within a few minutes : this clottino- 
does not occur in the normal aqueous (13), (28). The 
fluid, in contact with its clot, was preserved in a chemically 
clean glass vessel in an ice-chest for 24 hours before being 
examined. 

When blood was to be withdrawn the animal's ear was 
treated as previously mentioned. From a marginal vein 



104 Diagiiofiis in Uiicitifi. 

punctured with a large needle several ccs. of blood could 
be readily procured. It was preserved in the same way as 
the aqueous humour. 

4. The examination of the fluids for specific amboceptor. 

The components of the test were as follows : — {a) The 
mitig en. —This, in all, except the syphilitic and tubercular 
cases, was made from the identical organism that had 
caused the infection. An antigen should have (1) a high 
power of combining with its specific amboceptor ; (2) as 
low a power of combining with complement in a non- 
s]iecific manner as possible ; (3) regularity in its working. 

Bacterial antigens may be made by emulsifying organ- 
isms intact, or by extracting their endotoxins, and discard- 
ing their bodies. A great deal of work has been done on 
this subject (1), (10), (19), (22), (23), (28), The most 
prevalent view would appear to be that the bacterial ex- 
tracts are more satisfactory than the emulsions, having a 
lower anti-complementary power, and greater regularity 
in their working. T have employed both as antigens. The 
emulsions, bacteria in normal saline solution, were pre- 
jiared by being shaken for half-an-hour, heated at 60° C. 
for one hour, and preserved in the ice-chest after addition 
of one-half per cent, carbolic acid. The extracts were 
prepared by freezing an emulsion in liquid air, allowing it 
to thaw at room temperature, centrifuging down the bac- 
terial debris, and preserving the supernatant fluid in the 
ice-chest after addition of one-half per cent, of carbolic acid. 
The freezing of bacteria renders their protoplasmic cover- 
ings more permeable, and in this way allows for the libera- 
tion of their endotoxins. 

The li(iiiid air was procured for mt> thiough the kind 
assistance of Mr. Mosse. the Registrar of tlie Royal 
Dublin Society, and Dr. Henry Dixon. 

My ex[)erience as to the respective merits of these 
antigens is too limited to be of value, but I found the ex- 
tracts more satisfactory. The syphilitic antigen was one 
already iu use for " Wassermann " iciictiotis in the 
r;itli()l()gv School of Tiinitv College, it consisted of an 



Bv Dr. Ettphan Maxwfjj.. 105 

alcoholic extract of sheep's heart, to which was added 0.4 
Y>ev cent, of cholesterin. The tubercular antigen employed 
was Koch's "old tuberculin." Various preparations of 
the tubercle bacillus have been used in " fixation comple- 
ment " tests (3), (4), (11). In the hands of one observer — 
namely, Fraser — " old tuberculin " would ai)|>ear to have 
been the most satisfactory (15). 

(b) The jiuidfi for r.ramiuatio)!. — The clear aqueous arul 
the blood serum having been removed from their respective 
clots, they were heated at 57° C. for half-an-hour almost 
innnediately before examination. This destroys com])le- 
ment, leavino" amboceptor intact, and is described as in- 
activation. It should be noted here that althouf^h the ])i-e- 
senee of com]ilement in the normal aqueous hiunour has not 
apparently been ]iroved, it has been detected in cases of 
intraocular inflammation (-25), 34a). 

(c) The compU'Dicnt. — Fresh Guinea-pinj serum supplied 
this. Complement as used in this test should possess two 
qualities. 1st. Tt should show a readiness to be " fixed " 
by an antigen and its specific amboceptor. •2nd. It should 
possess the power, if not already " fixed," of readily 
activating the hnemolytic amboceptor on its addition in the 
second part of the test. 

I'nfortunately for the simplification of my technique, the 
complement in rabbit blood, while possessing an active 
hiPmolytic power, is not readily " fixable " (22). Guinea- 
pig complement, on the other hand, possessing both these 
qualities, w^as more suitable. A known amount of comple- 
ment was always em]iloyed in the carrying out of the test, 
hence the necessity for the inactivation of rabbit comple- 
ment, as previously mentioned. 

id) The hfrmolytic system. — This consisted of — 

(1) Sheep red-blood cells, freslily obtained, and well 
washed in normal saline solution. 

(2) Inactivated horse-serum, containing hiPmolytic 
amboceptor to sheep cells, as purchased from Messrs. Bur- 
roughs Wellcome & Co. 

These, then, are the com])onents of the test. I now turn 



106 Diaciuosiis; in Un'itifi. 

to a description of its technique. The method I used WPoS 
almost identical with that employed by Dr. Meldon, of the 
Westmorland Lock Hospital, in his " fixation of comple- 
ment " tests with syphilitic serums. He generously gave 
me the benefit of his past experience, and rendered me 
valuable assistance throughout. 

The quantities employed were as follows : — 
Antigen, suitably diluted — 80 cm. 
The fluid for examination — 20 cm. 
Complement suitably diluted — 40 cm. 
Ha^molytic system — 20 cm. 

This last was prepared by adding to one part of centri- 
fugalised red-blood cells two parts of liff-molytic serum 
diluted 1 in 100 — this mixture was in its turn diluted 
] in 10. 

Tf any of the components of the test were omitted, the 
total quantity of 100 cm. was maintained by the addition 
of normal saline solution, the diluting medium employed 
throughout. 

The diameter of the glass tubes used was 6 mm. These 
and the pipettes employed were all chemically clean. 

The following quantitative estimation of the suitable 
dilutions of antigen and complement was made preliminary 
to the test on every occasion. Varying dilutions of antigen 
and a fixed quantity of complement were incubated at 
87° C. for three-quarters of an hour. 

The ha^molytic mixture was then added, and the tubes 
were incubated for an hour. During this hour varying dilu- 
tions of complement added to the h;T>molytic mixture were 
also incubated. Tt may be here noted that the .sheep cells 
and li.i'iiiolytic amboceptor were always incubated after 
llicir mixture for half-an-hour before use, this rendering 
the laUer more active. Tlie two sets of tubes were left for 
about one houi' at room tempeintui'e before' the results were 
read off. The lowest dilution of antigen showing a trace 
of complement fixation was noted, and used in the final 
exaniinalion at a (uither dilution of 1 in 1. The highest 
dilution of coniplcnient allowing coinpletc hn'inolvsis was 



Bv Dr. KrrHAN Maxwrll. 107 

noted, and a dose two to three times stronger subsequently 
used. The incubation times in the test were the same as 
those just mentioned for the quantitative estimations. 

Each test was accompanied by the following controls : — 

(a) The antigen control. — This consisted of a mixture 
containing antigen, complement, and haemolytic system : 
if this tube did not show complete hfemolysis, positive 
results were of doubtful value. 

(h) The serum (aqueous humour) control. — This con- 
sisted of a mixture of the serum (aqueous) complement 
and haemolytic system : similarly here the absence of com- 
plete ha?molysis rendered positive results of doubtful value. 
It may be noted under this heading that serums (aqueous) in 
low dilutions may, in rare instances, give a negative result 
in " fixation of complement " tests, at the same time giving 
in the higher dilutions a positive result. This is said to be 
due to the concentration in the lower dilutions of ambocey)- 
toids. These bodies combine more readily with antigen 
than the amboceptors; they have, however, no power of 
combining with complement. 

Thus, although a specific interaction may have taken 
place, complement is left free to produce haemolysis and 
show a negative result (22). From this the importance 
of examining a range of dilutions may be seen. 

(c) The hcemolytic system control. — This consisted of a 
mixture of complement, cells and hapmolytic amboceptor. 
Complete haemolysis demonstrated the accurate working 
of these components. 

(d) The sheep cells control. — If a mixture of cells and 
normal saline solution showed any haemolysis, the cells 
were discarded as unfit for the test. 

(e) As a final control may be mentioned the testing of the 
serum (aqueous) with not only its specific but also a non- 
specific antigen. In this way the diagnostic value of a 
positive reaction could be more clearly demonstrated. 

The results of the test were estimated after the tubes 
had stood over-night at room temperature. 



12.4. 


15. 


19.4 


15. 


22.4 


15. 


29.4 


15. 



108 Diagnosis w Uveitis. 

The results were expressed in the recognised manner : — 
+ 3 = complete inhibition of hsemolysis. 

~ y grades of partial inhibition of haemolysis. 

= complete haemolysis. 
I now pass on to a resume of the separate tests. T pro- 
pose to group the first series, which aimed at the detec- 
tion of amboceptor in the aqueous humour, according to 
the organism injected. 

1. The Bacillus Coli. 
1st Experiment. 
-0. D. rabbit No. 1 injected two million Bacillus coli. 
Major part regurgitated subconjunctivally '- only 
conjunctivitis resulted. 
-0. D. injected three million Bacillus coli. 
-0. D. acute iritis. 

-Aq. h. O. D. examined with coli antigen. Antigen 
control inhibiting complement — test a failure. 
3.5.15. — Further attempt at examination failed, as with- 
drawal of sufficient aq. h. proved impossible 
owing to development of panophthalmitis. 

2nd Experiment. 

5.5.15.- — O. D. rabbit No. 2 injected five miUion B. coli. 
7.5.15.— O. D. iritis. 

13.5.15.^ — Aq. h. O. U. examined with coli antigen. 
Result : — Aq. h. O. D. undil. -f.^ 
„ O. S. „ +2 
antigen control -|-^ 

aq. h. ,, omitted. 

In this connection it should be noted that the 
anticomplementary actions of a serum (aq. h.), 
and an antigen are greater when mixed together 
than when tested separately ; positive results in 
cases of mild inhibition of antigen and serum 
should therefore be accepted with reserve. 
21 .5. 15. — Aq. h. (). I), withdrawn. Exauiiuation of no value, 
owing to admixtun' of blood. 



By Dr. Euphan Maxwell. 109 

Srd Experiment. 

1.6.15.— 0. 8. rabbit No. 3, injected 12 million B. coli, 

heated half hour 50° C. 
2.6.15.— 0. S. iritis. 
10.6.15. — Aq. h. O. U. examined with coli antigen. 
Result: — Aq. h. O. S. imdil. -\-'^ 
„ O. D. „ — 
Aq. h. control omitted ; other controls satis- 
factory. 
23 . 6 . 15. — Aq. h. 0. S. examined with coli and typhoid antigens 
Result : — Aq. h. 0. S. undil. coli a. +^ 

,, typhoid a. — 

In this and subsequent tests, controls, if not 
stated to the contrary, were satisfactory. 

Mh Exjieriment. 

31.5.15. — 0. 8. rabbit No. 4, injected 0.1 of 10 ccs. over-night 
broth culture of coli. 
2.6.15.— 0. 8. iritis. 

10.6.15. — Aq. h. O. U. examined with coli antigen. 
Result : — Aq. h. O. 8. undil. +^ 
„ O. D. „ — 
Aq. h. control omitted. 
23.6.15. — Aq. h. O. U. examined with typhoid antigen. 
Result: — Aq. h. 0. 8. undil. -f^ 
„ 0. D. „ — 
,, O. 8. control -f-^ 

2. 8taphylococcus Aureus. 
oth Experiment. 

1.9. 15. — 0. D. rabbit No. 5, injected 5 million staphylococci, 

heated 40 min. 58° C. 
6.9.15. — O. D. no reaction, injected 10 million st., similarly 

treated. 
8.9.15.— 0. D. mild iritis. 

Aq. h. 0. D. examined with st. antigen. 
Result : — Negative. 
15.9.15. — Aq. h. O. D. examined with st. antigen. 



110 Index to Biographical Notices. 

Result ;— Aq. h. 0. D. undil. +2 

,, control omitted, but subse- 
quently tested with slight 
blood admixture showed no 
inhibition. 
17.9.15. — 0. D. injected with st. extract : strength equivalent 

to four th. m. bacteria. 
18.9. 15. — 0. D. acute iritis. Further attempts at examination 
of aq. h. failed OAving to blood admixture. 

3. Typhoid Bacillus. 
6^^ Experiment. 
1.9.15. — 0. D. rabbit No. 6, injected five m. typhoid b. 
3.9.15.— 0. D. mild iritis. 
6.9.15. — 0. D. again injected as above. 
15.9.15. — 0. D. acute iritis. 

Aq. h. 0. D. examined with typhoid antigen. 

Result : — Negative, and valueless as subsequent 
examinations of antigen showing absence of 
antigenic power at strength used. 
(To be continued.) 



Art. VII. — An Index to the Biographical Notices that 
have appeared in the Journal since its comniencement 
in March, 1832. By T. Percy C. Kirkpatrick, M.D., 
M.R.I. A. ; Fellow and Registrar of the Royal College 
of Physicians of Ireland. 

The first number of the First Series of the Dublin 
Journal of Medical ScienIce was issued in March, 1832, 
and since that time the Journal has appeared with great 
regularity. Though it has always been a literary and 
critical rathei- than a news journal it has, from time to 
time, contained records of the lives of Irish medical men, 
often written by those who knew the subjects of the 
memoirs as valued personal Irieiuls. Such records are 
often the most important source of information that we now 
|)ossess about tlio leading Irish medical men of the ))ast. 
The accompanying Index is published in the hope that it 



By 1)11. T. r. C. KlRKPATRU'K. Ill 

will make these records more easily available lor the 
student of Irish medical history. 

The great majority of the biographies referred to in the 
Index were published as "obituary notices," and unfor- 
tunately many of them are very brief. Some, however, 
are regular biographical studies, giving a critical apprecia- 
tion of the man and his work. One must regret that the 
brilliant series of such studies, started in the early numbers 
of the Second Series of the Journal, was so soon abandoned. 
Such memoirs as those of Mosse, Eutty, O'Halloran and 
MacBride contain much valuable information about the 
history of Irish medicine in the eighteenth century, derived 
from sources not now available to the student. I desire 
to thank Mr. R. J. Phelps, Dun's Librarian, for the help 
that he has given me in the preparation of the Index. 

Index. 

Arderne, John. Vol. 76. October, 1883. V. 'im. 

(A. W. Gore.) 
Atkins, Ring-rose. Vol. 105. March, 1898. P. 272. 
Atthill, Lombe. Vol. 130. October, 1910. P. 286. 

Vol. 131. January, 1911. P. 49. 

Banks, Sir John Thomas. Vol. 126. August, 1908. 

P. 1.5.5. Portrait. (John W. Moore.) 
Banks, Perceval. Vol. 5. May, 1848. P. 569. 
Barry, Sir Edward. Vol. 128. December, 1909. P. 442. 

Portrait. (T. Percy C. Kirkpatrick.) 
Bellingham, O'Bryen. Vol. 64. November, 1877. 

P. 469. (E. Mapother.) 
Bennett, Edward Hallaran. Vol. 124. July, 1907. 

P. 78. (John W. Moore.) 
Benson, Arthur Henry. Vol. 134. December, 1912. 

P. 469. Portrait.' (John W. Moore.) 
Bigelow, H. J. Vol. 111. February, 1901. P. 129. 

(Review. ) 
Blyth, John. Vol. 93. March, 1892. P. 264. (John 

W. Moore.) 
Brady, Thomas. Vol. 37. May, 1864. P. 499. 



112 Index to Biuymijliical Notices. 

Brereton. David. Vol. 38. February, 1862. P. 258. 
Bnnviie, Sir Thomas. Vol. 120. October, 1905. P. 241. 

(J. Knott.) 
Butcher, Kichard G. H. Vol. 24. Kovember, 1857. 

Portrait. 
Butler, Isaac. (Irish Astrologer.) Vol. 4. August, 

1847. P. 271. 
Carmichael, Eichard. Vol. 9. May, 1850. P. 493. 

Vol. 11. 1851. Portrait. 

Chanca, Diego A. (of Seville). Vol. 122. November, 

1906. P. 383. 

Cheyne, John. 1st Series. Vol. 16. September, 1839. 

P. 108. (Review of Pettigrew's portraits,) 
Churchill, Fleetv/ood. Vol. 65. March, 1878. P. 285. 

(T. W. Grimshaw.) 
Clarke, James. Vol. 7. May, 1849. P. 481. (Review 

of Collins' Life of.) 
Colles, x\braham. Case of A.C. described by Dr. William 

Stokes. Vol. 1. May, 1846. P. 303.' 
Colles, William. Vol. 94. July, 1892. P. 94. (John 

W. Moore.) 
Collis, Maurice H. Vol.47. May, 18(59. P. 506. 
Connor, Bernard. Vol. 133. January and February, 

1907. Pp. 57 and 130. (J. Knott.) 

Corrigan, .S'/r Dominic J. Vol.69. March, 1880. I'. 268. 
Crampton, .S'/'r Philip. Vol.33. February, 1862. P. 245 

Vol.15. May, 1853. Portrait". 

Croly, Henry (iray. Vol. 1J6. October, 1903. P. 326. 

(John W. Moore.) 
Cruise, Sir Francis Richard. Vol. 133. April, 1912. 

1'. 314. I'oitiait. (Jolui W. Moore.) 
( 'liming, James. Vol. 108. October, 1899. V. 31(5. 

'James Ijittlc.) 
Ciinnnigham, Daniel John. Vol. 128. August, 1909. 

1\ 154. Portrait. (.\. l'\ Dixon.) 
Vol. 134. August, 1912. I'. 81. (James 

Ditlle.) 
Ciinan, John Oliver. Vol. 1. Novcunber, 1847. I'. 500. 

L'ortrait. 



hy J)K. T. i'. C. KiRKl'ATlUCK. 113 

Cusack, William James. Vol. 16. 1853. Portrait. 

Vol.33. February, 18(5'2. P. "255. 

Douglas, John C. Vol. 15. February, 1851. P. 248. 

(A. H. M'Clintock.) 
Dover, Thomas. Vol. 119. February, 1915. P. 133. 

(J. Knott.) 
Duiiey, Sir George F. Vol. 116. November, 1903. 

P. 405. (John W. Moore.) 
Dun, Sir Patrick. Vol. 2. August, 1846. P. 288. 

Portrait. 
Vol. 42. 1866. Pp. 231, 413. Portrait. (T. 

W. Belcher.) 
Eames, Henry. Vol. 55. April, 1873. P. 400 (a). 
Edward VII. Vol. 129. June, 1910. P. 466. (John 

W. Moore.) 
Faraday, Michael. Vol. 50. November, 1870. P. 371. 

(Eeview.) 
iPinaghty, James (Mesmerist). Vol. 4. August, 1847. 

P. 260. 
Finaen, Niels E. Vol. 118. December, 1904. P. 476. 

(H. Mygind.) 
FitzGibbon, Henry. Vol. 133. April, 1912. P. 319. 

(K. K. Leeper.) 
•FitzGerald, Charles Edward. Vol. 142. July, 1916. 

P. 69. Portrait. (John \V. Moore.) 
Fleury,J. C. Vol.25. February, 1858. P. 14. (A. H. 

M'Clintock.) 
Flood, Valentine. Vol. 5. February, 1848. P. 282. 
Foot, Arthur Wynne. Vol.110. October, 1900. P. 333. 

Portrait. (John W. Moore.) 
Fox, Michael. Vol. 94. December, 1892. P. 498. 
Eraser, Alexander. Vol. 128. October, 1909. P. 329. 

Portrait. 
Gall, Franz J. (Phrenologist). Vol. 121. May, 1906. 

P. 377. (J. Knott.) 
Gordon, Alexander. Vol. 86. December, 1888. P. 531. 

(R. Esler.) 
Gordon, Samuel. Vol. 105. June, 1898. P. 551. (John 

W. Moore.) 



114 Index to Biographical Notices. 

Graves, Kobert James. Vol. 15. February, 1853. 

P. xxiv. Portrait. 
Vol. 65. January, 1878. P. 1. (J. F. 

Duncan.) 
Greatrakes, Valentine (Mesmerist). Vol. 4. August, 

1847. P. 254. 

Vol. 77. February, 1884. P. 133. 

Greene, George. Vol. 1. May, 1846. P. 565. 
Griffin, William. Vol. 6. November, 1848. P. 485. 
Grimshaw, Thomas W. Vol. 109. February, 1900. 

P. 157. (John W. Moore.) 
Hamilton, Edward. Vol. 109. January, 1900. P. 77. 
Harkan, Patrick. Vol.33. February /l862. P. 258. 
Harrison, Kobert. Vol. 33. February, 1862. P. 249. 
Harvey, Joshua Eeuben. Vol. 73. February, 1882. 

p!^ 174. (A. W. Foot.) 
Haughton, Samuel. Vol. 104. December, 1897. P. 535. 
Helmont, J. B. von. Vol. 120. August, 1905. P. 132. 

(J. Knott.) 
Higgins, Brian. Vol. 8. November, 1849. P. 465. 

(Wm. K. Sullivan.) 
Higgins, William. Vol. 8. November, 1849. P. 465. 

(Wm. K. Sullivan.) 
Houghton, James. Vol. 4. November, 1847. P. 511. 
Houston, John. Vol. 2. August, 1846. P. 294. 

(Butcher.) 
Hudson, Alfred. Vol. 74. July, 1882. P. 1. (James 

Little.) 
Hunt, Perceval. Vol. 5. May, 1848. P. 567. 
Hutton, Edward. Vol. 41. February, 1866. P. 253. 
Jackson, Alexander. Vol. 5. May, 1848. P. 565. 
Jacob, Archibald Hamilton. Vol. 111. February, 1901. 

P. 159. 
Johns, Kobert. Vol. 38. August, 1864. P. 255. 
Johnson, Charles. Vol. 43. February, 1867. P. 206. 

(A. H. M'Clintock.) 
Johnstone, James. Vol. 1. February. 1846. P. 275. 
Joynt, Dep. -Surg. -General Christopher. Vol, 140. July, 

1915. P. 78. (John W. Moore.) 



By Dr. T. P. C. Kirkpatrick. 115 

Kane. Sir Robert J. Vol. 89. March, 1890. P. 286. 

(John W. Moore.) 
Keogh,John. (Herbalist.) Vol. lOG. July, 1898. P. "27. 

(H. S. Purdon.) 
Kidd, Cxeorge Hugh. Vol. 101. February and March, 

1896. Pp. 192, 286. 
Kidd, William Lodge. Vol. 12. August, 1851. P. 252. 
King, Henry. Vol.104. December, 1897. P. ^536. 
Kingsley, William. Vol. 33. February, 1862. P. 258. 
Larrey, Baron, Surgeon in Napoleon's Army. Vol. 34. 

August, 1862. P. 146. (Review,) 
Ledwich, Thomas Hawkesworth. Vol. 27. May, 1859. 

P. 455. 

Vol.33. February, 1862. P. 258. 

J^ees, Cathcart. Vol. 33. February, 1862. P. 258. 
Lister, Lord. Vol. 133. March, 1912. P. 240. (John 

W. Moore.) 
Little, Thomas (Sligo). Vol. 8. November, 1849. P. 494. 
Litton, Samuel. Vol. 5. February, 1848. P. 289. 
Long, John St. John. (Quack.) Vol. 77. February, 

1884. P. 133. 
Macan, Sir Arthur Vernon. Vol. 126. November, 1908. 

P. 412. Portrait. (John W. Moore.) 
M'Ardle, Capt. Joseph, R.A.M.C. Vol. 116. July, 1903. 

P. 79. (M. F. Cox.) 
MacBride, David. Vol. 3. February, 1847. P. 281. 

Portrait. (A. Smith.) 
MacCormac, Henry. Vol. 86. August, 1888. P. 161. 
M'Donnell, Robert. Vol. 87. June, 1889. P. 552. 

(John W. Moore.) 
MacDowel, Benjamin George. Vol. 80. October, 1885. 

P. 357. (John W. Moore.) 
M'Grigor, Stir. -Gen. Sir James. Vol. 34. August, 1862. 

P. 133. (Review.) 
M'Guire, Hunter Holmes. Vol. 110. November, 1900. 

P. 394. (G. M. Foy.) 
Mackness, James (Hastings). Vol. 12. November, 1851. 

P. 430. (Review.) 
Macnamara, Rawdon. Vol. 95. Mav, 1893. P. 454. 



IIG Index to Biographical Notices. 

Madden, Eichard Robert. Vol. 81. March, 188G. 

P. 286. 
Marsh, Sir Henry. Vol. 33. February, 1862. P. 251. 

Vol. 16^! August, 1853. Portrait. 

Maturin, Leslie. Vol. 79. January, 1885. P. 87. 

(John W. Moore.) 
Mayne, Robert. Vol. 37. May, 1864. P. 499. 
Meldon, Austin. Vol. 117. June, 1904. P. 471. (John 

W. Moore.) 
Montgomery, William Fetherstonhaugh. Vol. 33. Feb- 
ruary, 1862. P. 250. 

Vol. 22. August, 1856. Portrait. 

Moore, Charles Frederick. Vol. 117. February, 1904. 

P. 159. (John W. Moore.) 
Moore, Daniel. Vol. 5. February, 1848. P. 290. 
Moore, Robert Henry. Vol. 118. December, 1904. 

P. 475. Portrait. (John W. Moore.) 
Moore, William. Vol. 111. May, 1901. P. 397. (John 

W. Moore.) 
Morgan, Jerome. Vol. 41. February, 1866. P. 254. 
Mosse, Bartholomew. Vol. 2. November, 1846. P. 565. 

Portrait. (Fleetwood Churchill.) 
Neligan, John Moore. Vol. 36. August, 1863. P. 255. 
Neville, William Cox. Vol. 118. December, 1904. 

P. 479. 
Nixon, .S'/> Christopher John. Vol. 138. August, 1914. 

P. J 57. Portrait. (John W\ Moore.) 
Norman, ConoUy. Vol. J25. April, 1908. P. 316. (J. 

Magee Finny.) 
Xunn, Richard. Vol. 5. February, 1848. 1'. 292. 
O'Jioirne, James. Vol. 33. February, 18()2. P. 258. 
(J'Ferrall, .Joseph Michael. Vol. 64. November, 1877. 

P. 461. (E. Mapother.) 
O'Grady, Edward Stamer. Vol. 101. December, 1897. 

P. 535. 
O'Halloran, Silvester. Vol. (). August, 1848. P. 223. 

Portrait. 
November, 1848. 1'. 496. 



By Dk. T. V. C. KiT^KrATT^TCK. 117 

Osborne, Jonathan. Vol. 37. February, 1864. P. 249. 
Vol. 139. March, 1915. P. 161. (James 

Little and T. P. C. Kh-kpatrick.) 
Ould, Sir Fielding. Vol. 25. February, 1858. P. 1. 

Portrait. (A. H. M'Clintock.) 
Pakenham, Daniel. Vol. 41. February, 1866. P. 254. 
Pasteur, Louis. Vol.113. March, 1902. P. 206. (Re- 
view.) 
Porter, Sir George Hornidge. Vol. 100. July, 1895. 

P. 93. (John W. Moore.) 
Porter, William Henry. Vol. 33. February, 1862. 

P. 253. 
Power, John Byrne. Vol. 125. May, 1908. P. 399. 

(F. R. Cruise.) 
Purdon, Thoma.s Henry. Vol. 86. August, 1888. P. 164. 
Redfern, Peter. Vol. 135. ^farch, 1913. P. 236. 

Portrait. (W. H. Thompson.) 
Rutty, John. Vol. 3. May. 1847. P. 555. (Jonathan 

Osborne.) 
Rynd, Francis. Vol. 32. August, 1861. P. 248. 

— Vol. 33. February, 1862. P. 254. 

Sargent, Richard Strong. Vol. 2. May, 1848. P. 570. 
Serullus, George S. 1st Series. Vol. 2. September, 

1832. P. 103. 
Sibthorpe, Surg. -Gen. Charles. Vol. 121. June, 1906. 

P. 471. (John W. Moore.) 
Sinclair, Sir Edward Burrowes. Vol. 73. Mav, 1882. 

P. 462. 
Smith, Aquilla. Vol. 89. May, 1870. P. 476. (John 

W. Moore.) 
Smyly, Josiah. Vol. 37. February, 1864. P. 248. 
Smyly, Sir Philip Crampton. Vol. 117. Mav, 1904. 

P. 398. (John W. Moore.) 
Stoker, .9/r W. Thornley. Vol.134. July, 1912. P. 76. 

Portrait. (Joseph O'CarrolI.) 
Stokes, Whitley. 1st Series. Vol. 28. September, 1845, 

P. 165. 



118 Index to Biographical Notices. 

Stakes, William. Vol. 65. February, 1878. P. 186. 
(John W. Moore.) 

Vol. 19. February, 1855. Portrait. 

Vol.106. August, 1898. P. 133. (Review of 

" William Stokes : His Life and Work.") 
Stokes, Sf/> William. Vol.110. September, 1900. P. 237. 

(John W. Moore.) 
Swanzy, Sir Henry Rosborough. Vol. 135. May, 1913. 

P. 397. Portrait. (John W. Moore.) 
Vol. 135. June, 1913. P. 408. (C. E. Fitz- 

Gerald.) 
Sydenham, Thomas. Vol. 111. June, 1901. P. 438. 

(Review.) 
Symes, Wm. Langford. Vol. 132. November, 1911. 

P. 408. (James Craig.) 
Tagert, William. Vol. 33. February, 1862. P. 158. 
Taylor, A. Swayne, F.R.S. Vol. 70. October, 1883. 

" P. 269. 
Taylor, Thomas. Vol. 5. May, 1848. P. 573. 
Thomson, Samuel Smith. Vol. 9. February, 1850. 

P. 250. (R. Stewart.) 
Thomson, Sir William. Vol. 128. December, 1909. 

P. 472. 
-Vol. 129. January, 1910. P. 78. (J. B. Cole- 
man . ) 
Tuomy, Martin. Vol. 5. May, 1848. P. 571. 
Vesalius, Andrew. Vol. 97. 1894. Pji. 219, 296, 403 

and 497. (G. M. CiiUen.) 
Victoria, Queen. Vol. 111. March, 1901. P. 238. 

(John W. Moore.) 
Warren, i^'redcrick W. Vol.80. November. 1885. P. 4.39. 

(I), h). r^linii.) 
Wilde, Sir William Robert Wills. Vol. (H . May, 1876. 

P. .500. 
Wilmot, Saiimcl. Vol. 7. I*\>l)niary. IS 19. P. 254. 
Wilson, Henry. Vol.C)!. -Inly, 1H77. P. 98. 
Yeo, (Icarld Francis. Vol. 127. .iinic, l<)()7, P. 470. 

(.John W. Moore.) 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



The Diagnosis of Nervous Diseases. By Pfrves Stewart, 
C.B., M.D., Edin. ; F.R.C.P. ; Physician to the \Yest- 
minster Hospital ; Joint Lecturer on Medicine in the 
Medical School ; Physician to the West End Hospital for 
Nervous Diseases ; Membre Correspondant de la Societe 
de Neurologie de Paris; Corresponding Member of the 
Philadelphia Neurological Society ; Consulting Physician 
to H.M. Forces; Temporary Colonel A. M.S. Fourth 
Edition, Revised and Enlarged. London : Edward 
Arnold. 1916. Demy 8vo. Pp. viii + 589. With 283 
Illustrations from Original Diagrams and Clinical Photo- 
graphs, and three Coloured Plates. 

Ten years have elapsed since the first Edition of this 
standard work was published. In reviewing that Edition 
in the number of the Journal for June, 1907, we wrote : 
" Not only advanced medical students but medical prac- 
titioners also owe a debt of gratitude to Dr. Purves Stewart 
for having vi^ritten so excellent a work on the difficult sub- 
ject of nervous diseases." 

If that was our opinion in 1907, what must it be when 
we rise from a perusal of the leading features of the present 
really splendid fourth edition? 

We would point out that it is distinguished from its 
l^redecessors by the fact that, besides a considerable amount 
of general additions, it contains much valuable new infor- 
mation relating to organic lesions of the nervous system 
caused by wounds and shock, derived from cases which 
have come under the author's personal observation in his 
capacity as Consulting Physician to His Majesty' Forces 
in the Mediterranean. 



120 Vicvicirfi and Bihlioqraphical Noticrfi. 

In his preface , Colonel Pnrves Stewart writes as follows : 
" For the last year, attached as Consultino Physician to 
His Majesty' Forces in the Mediterranean, I have helped, 
both in hospital and in the field ^ to watch the most gallant 
patient in the world — the British soldier. Some observa- 
tions on organic war-injm'ies have formed the basis of an 
additional cha]iter. For permission to publish them T am 
indebted to the conrtesy of the Director-General, Sir Alfred 
Keogh." The preface is signed " Piirveft Stewart," and 
dated : " Salonika, May, 1916." 

When we turn to the chapter in question (Chapter XXVI), 
we find that it occupies some 70 pages of a demy octavo 
volume, and is in fact a substantial treatise on organic war- 
lesions of the nervous system. In the ojiening paragraphs 
of this chapter the author points out that from the medical 
and scientific stand]ioints there are important differences 
between the injuries of war and the diseases and accidents 
of ]ieace. 

He tells us that " focal lesions froui war-injuries in 
healthy young brains and spinal cords, if aseptic, are 
practically equivalent to physiological ex]>eriments, and the 
syndromes which result are different from those which 
occur in the course of disease." Again : " Owing to the 
healthy condition of the tissues originally damaged, the 
prospects of recovery after war-lesions of the nervous 
system are much greater than can l)e expected after lesions 
which result from disease." 

Can any information be more useful to the young Armv 
Medical Officer than that which is conveyed in these two 
short sentences? 

This Section of the work — for such it is rather than a 
"Chapter" — is profusely illustrated by some fifty photo- 
graphs and drawings. The whole is well-arrnnged — brain 
wounds, wounds of the s]Mnal cord, and wounds of the 
peripheral nerves being consid(M;e(l in se(|iience. 

War-lesions of the pciiplitMiil ium-vos an> extremelv 
common. For example, Ciiptain Aijhur Fvans and 
Colonel Turves Stewart himself had luidci' their personal 



Stewart — Tlte Diaqiiosifi of Ncrvmis Dhrnfirft. 121 

observa.tion exactly 300 cases within a single year. Of 
these, 17-2 (or 57.3 i)er cent.) were in the nerves of the 
upper limbs, inclusive of brachial jilexus lesions; 81 (or 
•n per cent.) in the lower limbs, inclusive of cauda equina 
lesions; whilst 42 (or 14 per cent.) were cranial-nerve pal- 
sies. (Page 531). 

But the " War Supi^ement " — as we may so term it — 
is by no means the only change in the present edition. 
The rapid advance of neurology within recent years neces- 
sitated a careful revision of the whole book — and, in par- 
ticular, of the parts dealing with cereliellar lesions, the 
neuroses, and the " vegetative nervous system." To this 
last-named subject a special chapter (XX. ) is devoted. We 
may quote the author's definition of the phrase : — "The 
Vegetative Nervous System innervates the non-striped 
muscles of the body generally, also the pupils, the various 
glands and viscera, the heart and blood-vessels, and the 
genital organs. It is developed by outgrowth from the 
cerebro-spinal system, with which it remains connected by 
afferent and efferent fibres." ..." The vegetative 
system has two great subdivisions — the sympathetic system 
proper and the automatic or para-sympathetic system. 
These two divisions are not only automatically distinct, 
but also physiologically antagonistic, mutually counter- 
balancing one another." (Page 351.) 

In Chapter I., on the anatomy and physiology of the 
nervous system, a description is given of the more important 
minor motor tracts, which, in addition to the great 
pyramidal or cortico-spinal tracts, enter the spinal cord from 
above. These are derived from subcortical motor centres, 
and constitute subsidiary subcortico-spinal tracts. The 
following are mentioned and described — the rubrospinal 
or pre -pyramid a] tract (Monakow's bundle), the tecto- 
spinal tract or ventral longitudinal bundle, the vef^tibiilo- 
apinal tract or dorfial longitudinal bundle, and the ponto- 
fipinal tract, derived from cells of the formatio reticularis 
of the pons. • 

In the same chapter the description of the cerebellum 

I 



122 Ecvinvs and Bihliographical Notices. 

has been much amplified. Eeference is made to the ex- 
perimental researches of v. Eynbeck, Eothmann and 
others, which demonstrated the existence of definite cor- 
tical co-ordination-centres corresponding with various 
muscle-oroups of the limbs, head, and trunk. Barany's 
recent observations are also quoted and described, both in 
this chapter and in Chapter XVI. on " Inco-ordination " ' 
— in the latter place under the heading " Vestibular 
Ataxia." The original account of what is now known as 
" Barany's Vorbei-zeigen," or mispointing, was published 
in the Wiener Kliui'iehe Woehcn.'ielirift , 1912, pages 2033 
to 2038. 

Comparing the present with the first Edition of this 
work, we notice a great improvement. Some of the sub- 
jects dealt with are treated in a much more systematic 
manner. Tn the first Edition, if the reader wished to look 
up a special point, it was necessary to consult the index, 
and then, on referring to the given page, perhaps only a 
bare mention of the point would be found. In the present 
Edition there is a more detailed description of man}' signs 
and symptoms, and two new chapters on "Disorders of 
Sleep" and " Intra-cranial Tumours " add greatly to the 
value of the work. 

The publisher, Mr. Edward Arnold, is to be con- 
gratulated on the manner in which the volume has been 
brought out. Binding, paper, and type leave nothing to 
be desired, and the illustrations are numerous and artistic. 



Aids fo Ohsfrtricft. By Samuel Nall, B.A., M.B. (Can- 
tab.), M.R.C.P. Lond. Bevised by C. J. Nrpran 
EoNdRiDCR, ]\r.D. (Vict.), F.R.C.S. (Rng.), M.R.C.P. 
Lond. ; Examiner to the Central Midwives Board, &c. 
Twenly-cighth thousand. Eighth I^'dition. Tjondon : 
Baillicre, 'J^indall Sc Cox. JUIO. Fcap. 8vo. Pp. 
viii.-l-216. 

A ciiiM) ;ilways expects 'a story lo coiiuncnce with " Once 
upon a liiiH'." ^^V must conunence our review in the same 



Sutton — The Diseases of Women. 123 

way by saying — Once upon a time practitioners going to 

midwifery cases were always accompanied by " Nail's 

Aids." The present system of training, in which practical 

midwifery is so greatly encouraged, has removed to a large 

extent the necessity for " Nail's Aids." It is still a useful 

book for the lazy student and the unsure practitioner, and 

it has been brought up-to-date by its present reviser, Dr. 

Longridge. Its ])urchaser will have expended half-a-crown 

beneiiciallv. 

P.. S. 



The Disea-'ies of Women. A Handbook for Students and 
Practitioners. By Sir John Bland Sttton, F.R.C.S., 
LL.D., Surgeon to the Middlesex Hospital ; and Arthur 
E. Giles, M.D., B.Sc, F.R.C.S., Senior Surgeon to the 
Chelsea Hospital for Women, &c. Seventh Edition, 
with 150 Illustrations. Demy 8vo. Pp. xv + o71. 
London : William Heinemann. 

We are often asked by students to recommend a text-book 
which they can read for the final examination ; we have 
the greatest difficulty in doing so. We are acquainted with 
many text-books for students, but we do not know an 
ideal one. The authors of these numerous writings seem 
to find it impossible to ))ut themselves in the position of the 
student — that is, the position of one who wishes to know 
and understand theoretically the small amount of ))ractical 
work which he has been able to fit into the all-too-short 
course in gynaecology which the various colleges require. 
Bland Sniton and Giles' "Diseases of Women" has been a 
favourite with students for some years. It is now in its 
seventh edition. It is a good book, but it falls lamentably 
short of the ideal. This edition has been thoroughly re- 
vised, and a new arrangement of the subject matter has 
been introduced. The " anatomical " system of classify- 
ing disea.ses has been given up and the " pathological " 
system has been adopted. This seems rational. The 
work is divided into five parts. The first deals with 



124 Pki'views and Bibliographical Notices. 

Development, Anatomy and Pathology, the second with 
" Diseases of the Female Reproductive Organs," the third 
with Diagnosis, the fourth with Treatment, and the fifth 
with Prognosis. This is the system which we criticise as 
being against the best interests of the student who does 
not wish to learn the disease in one part of his book, the 
diagnosis in another, and the treatment elsewhere. There 
are certain jioints which we would like to see more clearly 
set forth, among which we should like to draw special 
attention to the following : — There should be a more in- 
telligible definition of version and flexion ; there should be 
illustrations of " How to replace the uterus," and a de- 
scription of how to make the gynaecological examination 
in a Schroeder's chair should be illustrated. 

We reiterate : the work is a good one, and the student 
and practitioner will gain much from its perusal. With a 
little more thought it could be made ideal. 

B. S. 

The Practitioners Medical Dictionanj. By Georcie M. 
Gould, A.M., M.D., Author of " An Illustrated Dic- 
tionary of Medicine, Biology, and Allied Sciences," 
" The Student's Medical Dictionary," " Pocket Medical 
Dictionary," &c. Third Edition : revised and enlarged 
by R. J. E. Scott, M.A., B.C.L., M.D.. Fellow of 
New York Academy of Medicine, Editor of Hughes' 
Practice of Medicine," Gould and Pyle's "Cyclopedia 
of Medicine nnd Suigery," &c. Jjondou : H. K. Lewis 
(Kr('o.,Ltd. !'.)](;. DemyHvo. Pp. viii + 90-2. 

Dr. Gorr.i) is so well-known as a im^dical lexicograjiher 
that the appearance of his name on the title |)agt> of this 
dictionary almost disarms ciiticism. 

The work purports to contain all the woids and ))hrases 
generally used in Medicine and the allii'd Sciences, with 
their pi'oper piotuniciat ion, defivation, and definition. It 
is based on recent medical litcMat lu'e, and is stated to in- 
clude probably some twenty thousand n<'w words. In 



GoL-LD — The Practitioner's Medical Dictiunary. 125 

order to make room for these large additions many illustra- 
tions, " now familiar in the usual text-books and works of 
reference," have been omitted. Useful tables have, how- 
ever, escaped the pruning knife, and indeed form a feature 
of the work. 

Another method of limiting the size of the volume is open 
to criticism. In their preface the authors observe : "A 
dictionary is for casual use and brief consultation : there- 
fore the size of the ty))e need not be larger than legibility 
demands : . . . the result is a volume of about three- 
fourths the bulk of the previous Edition." We confess 
that, even with the aid of glasses, the type in the i)resent 
Edition is distinctly trying to the eyes. Compactness is 
further secured by the use of thin paper. 

Naturally this Dictionary has an American tinge, especi- 
ally in spelling — to see " aneurysm " so spelled is, how- 
ever, a welcome relief. Also, the United States Phar- 
macopoeia is given place of preference in regard to materia 
medica and pharmacy — indeed we notice that the new- 
nomenclature of the 1914 Edition of the British Phar- 
macopoeia has been overlooked, for " barbitone," " hexa- 
mine," " methyl-sulphonal," " centimil," " decimil," and 
such-like terms find no place in the dictionary before us. 

The Gould system of pronunciation is followed in the 
work. The alphabetical sound of the letter has been the 
key. Over a letter a long mark '" — " means that the letter 
in question has its usual alphabetical sound. For 
example, " aphose " is pronounced " ah'-foz " ; " cysta- 
mine," " sist'-am-en " ; " galactozyme," " gal-ak'-to- 
zim " ; "uterus," " ii'-ter-us." Surely on this system 
■' cradle " and " cranium " should be pronounced "knl-dl" 
and " kra-ne-um '" respectively, and not " kra'-dl " and 
" kra'-ne-um," as printed'? 

There are very few errors in the text. One notable one 
is the definition of " Dusart's syrup " — namely, " a pre- 
paration having for its chief ingredient ferric phosphate." 
There is no iron in Dusart's syru[), which is represented in 
the British Pharmacopceia by Syrup of the Lacto-i)hosphate 



1-26 Hevieics and Biblioyrapkical Notices. 

of Calcium. With it, by the way, the non-otftcial ferrous 
lactate goes admirably in the proportion of one grain to 
the drachm. 

The use of the term " Eponymic " in one of the sen- 
tences in the Preface, and the definition of the word in the 
body of the Dictionary (page 837)—" named after some 
person" (Greek, eVtow^to?) — suggest that the crusade 
against Greek — that most splendid and flexible of all the 
languages ever spoken by human tongues — happily has not 
yet made material way among our Trans- Atlantic cousins. 
We agree with the authors when they write : " Unfor- 
tunately many of our medical terms were coined by men 
who knew ' little Latin and less Greek ' ; but when once 
these terms gain currency, usage sanctions them, although 
[)hilologically incorrect. ' ' 

Although the title i)age bears the well-known name of 
the famous London |)ublishing firm — H. K. Lewis & Co., 
Limited — the book was printed by the New Era Printing 
Company, Lancaster, Pennsylvania, and was copyrighted 
in the present year by the ecpialiy well-known publishing 
firm of P. Blakiston's Son & Company, Philadelphia. 



Tu'ciil ij-Sfvcnth llcport of Ihc CIa])]unti MatcniUij 
Hospital (under Medical Women), Jeffreys Koad, 
London, S.W. 1<)1(). Pj). i>(). 

WhilI'; a summary of cases is embodied in this Keport , it is 
evidently intended chiefly for the lay public. It is a matter 
for regret that strong nieasui'es are no! taken (by the 
(loxcrnnicnl foi- choice) to insist on tbc publication of 
reliable statistical tables by all the maternity hospitals in 
the kingdom. 'J'his would effect nnich in maintaining the 
^^f;ttus of the hospitals of {',vv;[\, [Britain and Ireland, re- 
garded IVoni a scietitilic standpoint. 

ii. S. 



PART III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scientific Intelligence, 



"A PIONEER OF MODERN PATHOLOGY." 
Death of Professor Metchnikoff. 

Undkh the above heading The Times of Monday, July 17, 
1016, publishes an appreciative obituary of the late Professor 
^letchnikoff, whose death occurred at the Pasteur Institute, 
Paris, on the evening of Saturday, July 15, after an illness 
of some months duration. 

By kind permission of tlie Editor, we reprint from tlic 
columns of The Time^i the biography of the great scientist, 
whose life-work has thrown s\ich a flood of light on the i)ro- 
cesses of inflammation and has given him a niche in the 
Temple of Fame alongside the great names of Louis Pasteur 
and of Joseph Lister: — 

" Elias Mecznikow or ' Elie Metchuikoff,' as he was called 
in France, was born on ^lay 15, 1845, at Ivanavka, the pro- 
])ei'ty of his parents, in the Russian province of Kharkoff. 
His father was a Russian whose Moldavian ancestor followed 
Prince Cantemir into Russia as ' sword-bearer ' in the be- 
ginning of the eighteenth century. ' ^letchnikoff ' is the 
Russian translation of ' sword-bearer.' Metchnikoff's father 
was an officer of the Imperial Guard, and retired with the 
rank of Major-General. Metchnikoff's mother, whose family 
name was ' Nevakowitch,' was of Jewish origin. 

From his childhood Elie Metchuikoff showed a strong 
taste for the study of nature. When he was 11 years old he 
entered the ' lycee ' or ' high school ' of Kharkoff, and at 
the age of 17 entered the University of Kharkoff, where he 
completed his studies and degree-examinations in two years 
in order to proceed in 1864 to Germany for further biological 
training. He went first to Heligoland (then a British pos- 
session) to study marine organisms. From Heligoland he 



128 A Pioneer of Modern Patholoijij. 

went, in 1865, to Lenckart, who gave him a place in his 
laboratory at Giessen, where he was then professor. In 1866 
Metchnikoff followed Lenckart to Gottingen on the latter's 
promotion to that university. Thence he went for a few 
months to von Siebold at Munich, and then to Naples. He 
returned to Eussia in 1867 to present his thesis for the 
doctorate, and was made ' docent ' in Zoology, first at Odessa 
and then at Petrograd, but after a few months there was 
appointed in 1870 ' Professor Ordinarius ' of Zoology and 
Comparative Anatomy at Odessa. 

" RESEARCHES IN ZOOLOGY. 

" Id 1808, at the age of 23, Metchnikoff married Mile. Lud- 
milla Federovitch, a charming girl, who unhappily was 
attacked by pulmonary tubercle, and in spite of every care 
and a long sojourn with her husband in Madeira, died there 
in 1873. In 1875 Metchnikoff married again. His second 
wife, who has ever since been his devoted companion and 
active aid both in the laboratory and in literary work, was 
Mile. Olga Belocoyitoff, and was only 17 when she completed 
her studies in the ' lycee ' of Odessa and became Mme. 
^letchnikotf . She attended after her marriage the professor's 
zoological teaching in the university, and has been a valued 
assistant in her husband's work. At the time of his second 
maniage Metchnikoff was in full and enthusiastic work as an 
embryologist. He and his distinguished friend Kowalewsky, 
of Petrograd, between 1866 and 1886 laid the foundations 
and built the main structure of that ' cellular embryology 
of the invertebrates, which has since become an essential 
and fruitful department of zoological doctrine. 

" In 1882, after twelve years at Odessa — when disturbances 
broke out in the university in connection with the assassina- 
tion of the Tsar Alexander II. — Metclniikoff migrated to 
]Messina. It was here that Metchnikoff 's views with regard 
to ' ))iiag()cytosis,' the function of the colourless floating 
corpuscles (oi- ' phagocytes,' as he called them) of the blood 
and lyinpli of lowei- animals as well as vertebialt-s, took shape. 
He published in 1882 a j)ath-breaking paper on ' Intracellular 
Digestion,' in which lie showed that this process goes on not 
only in the animalcules, like amo'ba, but in the cells of the 
surface layer (ectod<n'm) of sponges and in those of the mid- 
layer or mesoderm of jelly-fishes and of I r:insi»ai-ent marine 
larva", in which, owing to this transparency, the living cells 
and their Mio\-enients could l)e studied. This was a LU'eat dis- 



A Pioneer uf Modern I'athuloijij. 1:20 

covery, for, although Haeckel had in 1857 observed the engulf- 
ing of particles of verniiliou powder by the anict^ba-like colour- 
less corpuscle of the blood, the fact of the regular and normal 
intracellulai- digestion of organic particles by such cells and 
of the wide, in fact universal, occurrence of the process in the 
animal kingdom had not been known. 

" Metchnikoff immediately connected his discovery with 
Pasteur's great demonstration of the production of infective 
diseases by the fermentative activities of various specific 
disease-causing bacteria and allied ' microbes.' He wrote at 
once a memoir entitled ' The Struggle of the Organism against 
Microbes,' in which he enunciated the view that the 
phagocytes have been developed and established by natural 
selection in the animal organism, chiefly as a protection 
against intrusive disease-causing bacteria, though also acting 
as ' scavengers,' which remove all intrusive foreign bodies 
and dead or injured bits of the organism of which they are 
part. He was able, in 1884, to adduce a demonstrative case 
in the infection of some water-tieas (Daphnia) by a kind of 
yeast (JMonospora) which multiplies in their blood and kills 
them. Owing to the trans])arency of the water-flea, Metch- 
nikoff was able to watch and to publish convincing drawings 
of the activity of its phagocytes, which he saw engulfing the 
minute parasitic yeast, and thus in some cases successfully 
arresting the disease, though in others the infecting yeast 
gained the upper hand, and caused the death of the water- 
flea. The zoological studies which had been for twenty years 
the essential l)asis of Metchnikoff "s scientific development 
were now put aside. Henceforth he was a pathologist. 



THE DOCTRINE OF PHAGOCYTOSIS. 

" He returned in 1886 to Odessa for a brief time as director 
of a new bacteriological laboratory, with the determination 
to devote his life to the development of his doctrine of 
' phagocytosis.' In 1888, requiring greater facilities for his 
work, he went (after happily failing to receive encouragement 
in Germany) to Pasteur, in Paris, who gave him a laboratory 
in the Ecole Normale (Kue Vaugirard), where the great 
French discoverer was then established. Pasteur afterwards 
gave him ample laboratories and assistants in the new Institut 
Pasteur in the Rue Dutot. Having, as we have seen, brought 
his theory of |)hagocytosis into relation with the Darwinian 
doctrine of natural selection and with Pasteur's doctrine of 



130 A Pioneer uf Modern Vaihologij. 

microbes as the agents of disease, he proceeded to apply it 
further to the recently discovered facts as to inflammation. 

" With a growing body of investigators who came to Paris 
in order to work in his laboratory, Metchnikoff pursued with 
triumphant success, but not without opposition — especially 
from the older and more ignorant medical men — the establish- 
ment of his views as to the essential importance of ' phagocy- 
tosis ' in resistance to disease. In 1892 he produced a re- 
markable and fully illustrated volume on ' The Comparative 
Pathology of Inflammation,' in which he showed that that 
process is essentially a curative one — namely, a local arrest 
of the blood stream under the control of the nervous system, 
resulting in the out-wandering of phagocytes chemically 
attracted to an injured spot where, rapidly arriving like an 
innumerable crowd or army of scavengers, they proceed to 
engulf and digest tissue which has been killed by injury, and 
to isolate or destroy injurious intrusive substances. 

Metchnikoff thus finally ' explained ' the process of in- 
flammation. His attention and that of his pupils was now 
given for some years to the great question of ' immunity ' 
How is it that some individuals are either free from the 
attacks of parasitic micro-organisms to which their fellows 
are liable, or, it attacked, suffer less seriously than others 
do'.' To answer this question is to go a long way to the solu- 
tion of the great practical question as to how to produce im- 
nuniity to infective disease in man. In 1901 he published 
his great book on ' Immunity in Infectious Diseases.' With 
that convincing method of argument which he has always 
used — namely, the production of careful records of ex])eri- 
ment, thus setting forth his conclusions and meeting the 
objections of other observers, step by step — he established 
the doctrine that it is to the healthy activity of our phagocytes 
that we have to look, not only for temporary ])rotection, but 
for immunity against the micro-organisms of disease. It is 
(he phagocytes which act upon tlie ' toxins ' or poisons of 
disease-causing bacteria, and, converting llu-m into ' anti- 
toxins," are the actual agents of immunity. 

In the midst of his worl\ on immunity IMetchnikoff has 
found time in later years to study the bacterial flora of the 
alimentary canal, originally with the pur])ose of actpiiring fur- 
ther knowledge and control of diarrluea, dysentery, and 
cholera. In the course of these studies lie has been led to 
the conclusion that very generally the absorption of the 
poisonous products of the (leconi])osition set up by bacteria 



.4 Pioniir of Mixicni Pathohujij. 131 

in the lar^a- intestine (colon) is a cause of ill-health in man- 
kind, and promotes those changes in the tissues (the harden- 
ing of the arteries and the destruction of the ' nobler ' tissues, 
such as that of the brain and great glands) which lead to 
senility and to an earlier death than would occur in their 
absence. To check this decomposition he has mad-e use of a 
diet including sour milk and excluding alcohol. These are 
suggestive, but, at the moment, less conclusive ])ortions of 
Metchnikoff's work. They have attained greater publicity 
than his works on phagocytosis, inflammation, and immunity, 
owing to the fact that he has discussed them and the cause 
and significance of ' old age ' together with other profoundly 
interesting subjects in a popularly written book, ' The Nature 
of Man,' ])ublished in 1903, and translated into English. 

" !Metchnikof¥ was an honorary D.Sc. of Cambridge, a 
foreign member and Copley medallist of the Royal Societj', 
a member of the Institute of France (Academy of Sciences), 
and of the Academy of Sciences of Petrograd and of many 
other societies. In 1908 he was awarded the Nobel ]\ledal 
and Prize for his researches on immunity." 



ROVAL COLLEGE OF SURGEONS IX IREL.\XD. 

ThI'; annual election of the President, Vice-President, and 
Council was held on Friday, June 9, 1916, and the following 
were elected for the ensuing year: — President — Taylor, 
William. ^'ice-President — Stoiy, -lohn B Secretaryship 
of the College — Cameron, Sir Charles A. Council — Stoker, 
William; Cameron, Sir Charles A; Ormsby, Sir Lambert H. ; 
Purefoy, Eichard 1).; Sherlock, Henry Gregg; Myles, Sir 
Thomas; Flinn, 1). Edgar; Chance, Sir Arthur; Boyd, Shep- 
herd :\rc. ; Woods, Sir Robert H. ; M'Causland, R. Bolton; 
Gordon, Thomas E. ; Taylor, Edward H. ; Dwyer, F. Conway ; 
Blayney, Alexander J. M'A. ; INIaunsell, E. Charles B . ; 
Smith, Trevor N. ; W'heeler, William Ireland de C. ; Ball, Sir 
C. Arthur. 

The following resolution was adopted : — "That we, the 
President, Vice-President, and Members of the Council, on 
behalf of the Royal College of Surgeons in Ireland, humbly 
beg to express to His Gracious jNIajesty King George V. and 
to His Majesty's Government our profound regret at the 
great loss which the Empire has sustained by the death of 
Field-Marshal Earl Kitchener, K.G., K.P., O.M." 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics. 

For four iceelcs ended Snitirdaij, Jnli/ 15, 1916. 

IRELAND. 

The average annual death rate represented by the deaths — 
exclusive of deaths of persons admitted into public institu- 
tions from without the respective districts — Hegistered in 
the week ended Saturday, July la, 1916, in the Dublin 
Registi-ation Area and the eighteen principal provincial 
Urban Districts of Ireland, was 15.0 per 1,000 of the aggre- 
gate population, which for the purposes of these returns is 
estimated at 1,122,268. The deaths from all causes regis- 
tered in the week ended Saturday, July 15, and during the 
period of four weeks ended on that date, respectively, were 
equal to the following annual rates per 1,000 of the popula- 
tion : — 

Nineteen Town Districts, 15.0 and 15.1; Dublin Registra- 
tion Area, 18.8 and 17.7; Dublin City, 20.6 and 18.9; Belfast, 
14.7 and 13.9; Cork, 6.8 and 12.8; Londonderry, 13.0 and 
12.4; Limerick, 23.0 and 14.9; and Waterford, 7!^6 and 19.9. 

The deaths from certain epidemic diseases — namely, enteric 
fever, typhus, sinall-pox, measles, scarlet fever, whooping- 
cough, diplitheria, dysentery, and diaiThoeal diseases — regis- 
tered in the 19 town districts during the week ended Saturday, 
July 15, were equal to an annual rate of 0.9 per 1,000. 
Among the 110 deaths from all causes in Belfast were 1 from 
enteric fever, 4 from measles, 1 from whooi)ing-cougli, 2 from 
scarlet fever, and 1 (of a child under 2 years) from diarrluea 
and enteritis. Tlic 17 deaths from all causes in Ijimerick 
included 1 death from u h(joping-cough. Of the 4 deaths 
from all causi's rcgisteied in Waterford, 2 wnv from whoop- 
ing-cough. Of the 7 deaths recorded in Poitadown, 1 w.is 
ascribed to diphtheria. 

DUJiLIN REGISTRATION AREA. 

Tile Dublin Registration Area consists of the City of l)ul)liii 
as extended by the l^ublin Corporation Act, 1900, together 
with th(« Urban Districts of Rathmines, Pembroke, Blackrock 
and Kingstown. The population of the area is 397,000, that 



Sanitary and Meteorological Notes. 133 

of the city being 303,000, Rathmines 39,000, Pembroke 
29,100, Blaekrock 8,900, and Kingstown 16,400. 

In the Dublin Registration Area the births registered dxu'ing 
the week ended July 15 amounted to 182 — 91 boys and 91 
girls, and the deaths to 151 — 88 males and 63 females. 

DEATHS. 

The deaths registered, omitting the deaths (niiirihering 8) 
of persons admitted into jjuhlic institutions from localities 
outside the Area, represent an annual rate of mortality of 
18.8 per 1,000 of the population. During the twenty-eight 
weeks ended with Satui'day, July 15, the death rate averaged 
21.5, and was 1.2 below the mean rate for the corresponding 
portions of the 10 years 1906-15. The rate for all deaths 
registered diuing the twenty-eight weeks was 23.1, and for 
the corresponding period of the preceding 10 years it had 
been 23.9. 

The 143 deaths appertaining to the Area included 1 from 
measles, 1 from scarlet fever, 2 from whooping-cough. 1 (of a 
child under2 3^ears of age) from diarrhcpa and enteritis, and 1 
from influenza. In the thi*ee preceding weeks deaths from 
measles had numbered 3, 1, and 0; from scarlet fever, 1, 1, 
and 2; from whooping-cough, 1, 0, and 1; from diarrhcea and 
enteritis of children under 2 years, 2, 1, and 8; and from 
influenza, 0, 0, and 1, respectively. 

Tuberculosis caused 20 deaths, as against 33, 27, and 2o, 
respectively, in the three weeks preceding. Of the 20 
deaths ascribed to tuberculosis, 16 were referred to pulmonary 
tuberculosis, 3 to tubercular meningitis, and 1 to dissemi- 
nated tuberculosis. 

Eight deaths were caused by cancer, 9 by pneumonia 
(2 by broncho-pneumonia, 3 by lobar pneumonia, and 4 by 
pneumonia, type not distinguished), 13 by organic diseases 
of the heart, and 8 by bi-onchitis. 

Among deaths of infants under one year old, 1 was ascribed 
to congenital malformation. 5 to prematurity, and 4 to con- 
genital debility. 

Twenty-nine deaths were due to violence, of which 27 were 
caused by gunshot wounds, &c. 

Twenty-nine of the deaths registered diu'ing the week ap- 
pertaining to the Area were of children under 5 years of age, 
17 being infants under one year, of whom 10 were under one 
month old. 

Of the 143 deaths recorded, 55 occurred in hospitals and 
other public institutions. 



134 



Sanitary and Meteorological Notes. 



STATE OF INFECTIOUS DISEASE. 

The following returns of the number of cases of Infectious 
Diseases notified under the " Infectious Diseases Notifica- 
tion Act, 1889," and the " Tuberculosis Prevention (Ireland) 
Act, 1908," have been furnished by the respective sanitary 
authorities : — 

Table I. 

A dash ( — ) denotes that the disease in question is not notifiable in the District. 



CITIKS aNI» Week 

ihiHAN Districts eii<Uii|! 



= 23 

5 ip!. 



= H 



City of Diiltlin 



rtutliiiiiiia-< kikI 

IJrhHn 
Dixtriot 

Palilbroke 
Urban 

DiHtrict 



Blackrock 
Urban 
District 



Kingstown 

Urban 
Difltrici 



City o( HwlfaNt 



City of Cork 



City of Lnndoii- 
d«rr) 



City of Liiiiirick J 



City of Waleifoiil 



June 24 
July 1 
July 8 
July 15 

June 24 
July 1 
July • 
July 15 

June 24 

July 1 

July 8 

July 15 

June 34 
July 1 
July 8 
July 15 

June 24 
July 1 
July H 
July U 

June J4 
July 1 
J uly « 
July 15 

June 24 
July I 
July S 
July IS 

June 24 
July I 
July » 
July 15 

.lune 24 
July 1 
Julv 8 
July 15 

.Tune 24 
July 1 
July 8 
July 15 



a Continued fever. 



6 Not Inrludlng one case of varicella. 



Sanitary and Meteorological NoUs. 



1.35 



Cases of Infectious Diseases under Treatment in Dublin 
Hospitals. 

Table II. exhibits the number of cases of certain infectious 
diseases treated in the Dublin Hospitals during the week 
ended July 15, 1916, and the number under treatment at the 
close of each of the three preceding weeks. 

Table II. 





No. of CJases in Hospital 








Diseases 


at close of week ended 


Week ended July 15 












No. 














under 








No. 


Dis- 


Died 


treat- 




.Tune 24 


July 1 July 8 


admitted 


charged 




ment 
















at close 










1 






of week 


Enteric Fever 


17 


19 


20 


1 

6 


1 


— 


25 


Typhus 


2 


2 


2 


1 "" 


— 


— 


2 


Small-pox - 




— 


— 


! — 


— 


— 


— 


Measles - 


33 


34 


35 


8 


15 


1 


27 


Scarlet Fever 


50 


61 


60 


i ^^ 


13 


2 


57a 


Diphtheria - 


28 


22 


23 


! 5 


5 


— 


23 


Pneumonia - 


17 


15 10 

1 


2 


r> 


1 


6 



a Exclusive of 19 patients in " Beneavin," the Convalescent Home of Cork 
Street Fever Hospital. 



From this Table it appears that the cases admitted to 
hospital during the week ended Juh' 15, and the eases under 
treatment at its close, respectively, were as follows : — Enteric 
fever, 6 and 25 ; measles, 8 and 27 ; scarlet fever, 12 and 
57; and diphtheria, 5 and 23. Two cases of pneumonia 
were admitted during the week, and 26 remained under treat- 
ment at its close. Of the deaths in hospitals during the 
week, 1 was from measles, 2 were from scarlet fever, and 1 from 
pneumonia. Two cases of typhus fever remained in hospital 
at the clnse of the week. 



136 Sanitary and Meteorological Notes. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, July 15, in 96 
large English towns (including London, in which the rate was 
10.8), was equal to an average annual death rate of 10.7 per 
1,000 persons living. The average rate for 16 principal towns 
of Scotland was 12.6 per 1,000, the rate for Glasgow being 
as. 7, and that for Edinburgh, 13.3. 

Infectious Diseases in Edinburgh. 

The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for 
Edinburgh, with a copy of his Return of Infectious Diseases 
notified during the week ended July 15. From this Report 
it appears that of 57 cases notified, 19 were of scarlet fever, 
10 of diphtheria, 13 of pulmonary tuberculosis, 14 of other 
forms of tuberculosis, and 1 of enteric fever. Among the 430 
cases of infectious disease in hospital at the close of the 
week were 153 of pulmonary tuberculosis, 151 of scarlet fever, 
87 of diphtheria, 15 of measles, 5 of enteric fever, 4 of J cerebro- 
spinal fever, 2 of erysipelas, and 1 of whooping-cough. 



Meteorology. 



Abstract of Observations wade in the City of Dublin, Lat. 53° 20' 
N., Long. 6° 15' W.,for the Month of June, 1016. 

Mean Height of Barometer. - - - 20.948 inches. 

Maximal Height of Barometer (1 6th, at n.in.), 30.341 
Minimal Height of Barometer (4th. at p.m.), 20.253 
Mean Dry-bulb Temperature, - - - 53.2°. 

Mean Wet-bulb Temperature, - - 49.6". 

Mean Dew-point Temperature, - - 46.1°. 

Mean Elastic Force (Tension) of Aqueous Vapour. .315 inch. 
Mean Huiui(bty, . . . - 77.5 per cent. 

High(«st Temperature in Shade (on 17th), - ()9.0". 
Iv(»west Temperature in Shade (on Sth), - 40.0". 

Fiowest Temperature on Grass (Radiation) (Otli), 3().2°. 
Mean Amount of Cloud, - - - 56.7 percent. 

Rainfall (on 18 days). - - - - 2.363 inches. 

Greatest Daily Rainfall (on 3(Mli). - - .626 inch. 

General Directions (.f Wind, - - N.W., N.E., N., W. 



Sanitary and Meteorological Notes. I.'i7 

Remarks. 

A cool month, with preponderating N.W., N., and N.E. 
winds. It was the coldest Jnne on record within the past 
50 years. The mean temperature was 54.1°, or 3.8° below the 
average of June in Dublin. Other cold Junes were those of 
1869 (56.0°), 1879 (55.9-), 1882 (55.8^), 1888 (55.1°), 1903 
(56.0°), 1907 (55.4°), and 1909 (54.8°). It will be seen that 
June, 1916, was colder than the coldest of that series (1909) by 
0.7°. The weather was fine and dry from the 10th to the 20th 
inclusive. From the latter date to the close it was again 
showery. Most of the heavj' rainfall entered to the 30th 
occurred in the early morning hours of Jnly 1. .546 inch 
falling between midnight and 9 a.m. of that da}'. 

In Dublin the arithmetical mean temperature (54.1°) was 
below the average (57.9°) by 3.8° ; the mean dry-bulb readings 
at 9 a.m. and 9 p.m. were 53.2°. In the fiff^^ years ending 
with 1916, June was coldest in 1909 (M. T. = 54.8°), 1907 
(M. T. = 55.4°), 1882 (M. T. = 55.8°), and 1879 (" the cold 
year ") (M. T. = 55.9°). It was warmest in 1887 (M. T- = 
62.3°), 1896 (M. T. = 61. 4'), and 1899 (M. T. = 61.3°). 
June 1916 has therefore estabHshed a record for coldness. 
In 1915 the M. T. Avas 57.3°. 

The mean height of the barometer was 29.943 inches, or 
0.026 inch above the corrected average value for June — 
namely, 29.917 inches. The mercury rose to 30.341 inches 
at 9 a.m. of the 16th, and fell to 29.253 inches at 9 p.m. of 
the 4tli. The observed range of atmospheric pressure was, 
therefore, 1.088 inches. 

The mean temperature deduced from daity readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 53.2°, or 2.3° 
above the corresponding M, T. for May, 1916. Using the 
formula. Mean Temp. = Min. -\- {Max. — Min.) x .465, the 
value was 53.6°, or 3.8° below the average mean temperatiu'e 
for June, calculated in the same wa}^ in the thirty-five years, 
1871-1905, inclusive (57.4°). The arithmetical mean of the 
maximal and minimal readings was 54.1°, compared Avith a 
thirty-five years' average of 57.9°. On the 17th the ther- 
mometer in the screen rose to 69.0° — A\ind, N.E. ; on the 8th 
the temperature fell to 40.0° — wind, W.N.W. The minimum on 
the grass was 36.2°, on the 9th, The mean maximum was 



138 Sanitary and Meteorological Notes. 

60.V ; the mean miniinuni was 48.0'' ; the mean grass minimum 
was 44.6°. 

The rainfall was 2.363 inches on 18 days. The average 
rainfall for June in the thirty-five years, 1871-1905, inclusive, 
was 1.990 inches, and the average number of rain-days was 15. 
The rainfall, therefore, and the rain-days also were above the 
average. In 1878 the rainfall in June was very large — 5.058 
inches on 19 days ; in 1879 also, 4.046 inches fell on 24 days. 
On the other hand, in 1889, only .100 inch was measured on 
6 days. In 1887 the rainfall was only .252 inch, distributed 
over 5 days. June, 1910, established an undisputed record for 
excessive rainfall in Dublin — the measurement being 6.211 
inches on 19 days. In 1914 only .878 inch fell on only 9 days, 
and in 1915, 1.617 inches on 13 days. 

The rainfall in Dublin during the six months ending June 
30th amounted to 17.011 inches on 123 days, compared with 
11.107 inches on 95 days in 1915, 9.010 inches on 94 days in 
1914, 15.097 inches on 104 days in 1913, 13.756 inches on 110 
days in 1912, 7.729 inches on 80 days in 1911, 18.632 inches on 
111 days in 1910, 12.061 inches on 84 days in 1909, 11.729 
inches on 107 days in 1908, 12.336 inches on 108 days in 1907, 
12.641 inches on 109 days in 1906, only 6.741 inches on 67 
days in 1887, and a thirty-five years' average of 12.030 inches 
on 96 days. 

High winds were noted on 7 days, but never reached gale 
force (8). Hail fell on the 2nd, 6th, 9th and 30th. Thunder 
occurred on the 2nd, and there was a brief thunderstorm on 
the afternoon of the 9th. Solar halos were seen on the 3rd 
and 14th. 



At the Normal Climatological Station in Trinity College, 
Dublin, the observer, Mr. Thomas Mulock Bentley, B.A., 
reports that the arithmetical mean temperature was 53.5°, the 
mean dry-bulb reading at 9 a.m. and 9 p.m. being 53.9°. The 
thermometer rose to 72° in the shade on the 17th, and fell to 38° 
on the 7th and 8th. The grass minimum was 32° on the 14th. 
Rain fell on 18 days to the amount of 2.274 inches, .55 inch 
being measured on the 30th. The number of hours of bright 
sunshine registered by the Campl)ell-Stokes sunshine recorder 
was 169.3, giving a daily average of 5.6 hours. The corre- 
sponding figures for 1905 were 217.6 hours and 7.3 hours ; 



Sanitary and Meteorological Notes. 139 

1906, 210.3 and 7.0 ; 19.07, 129.4 and 4.3 ; 1908, 181.4 and 6 ; 
1909, 158.7 and 5.3 ; 1910, 139.9 and 4.7 ; 1911, 190.9 and 6.4 ; 
1912, 161.7 and 5.4 ; 1913, 173.5 and 5.8 ; 1914, 168.5 and 5.6 ; 
and 1915, 172.4 and 5.7. The mean earth temperature read 
at 9 a.m. was 56.9° at a depth of one foot below the surface of 
the ground, 53.7° at a depth of 4 feet. 



At Ardgillan, Balbriggan, Co. DubUn (210 feet above sea- 
level), Captain Edward Taylor, D.L., measured 2.47 inches 
of rain on 16 days, the heaviest fall in 24 hours being .60 inch on 
the 30th. The rainfall was .27 inch above the average of 
twenty-three years, while the rain-days were 3 in excess. 
Temperature in the screen rose to 69.9° on the 17th, and fell to 
36.9° on the 8th. From January 1 to June 30, 1916, the 
rainfall at Ardgillan amounted to 17.02 inches, or 4.56 inches 
more than the average, and the rain-days numbered 122, or 
30 in excess. The extremes of rainfall in June at Ardgillan 
in recent years have been — greatest, 4.62 inches in 1910 on 
17 da3^s ; least, 1.20 inches in 1904 on 11 days. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, was 2.53 inches on 17 days. The heaviest fall in 
24 hours was .37 inch on the 30th. The Malahide rainfall 
for 1916 to June 30 amounts to 15.81 inches on 119 days. 
On May 5, 2.295 inches fell. 

At the Ordnance Survey Office, Phoenix Park, Dublin, 
rain fell on 16 days to the total amount of 2.08 inches, 0.45 
inch being registered on the 30th. The duration of bright sun- 
shine was 186.4 hours, the largest daily duration being 15.9 
hours on the 15th. 

According to Mr. J. Pilkington, the rainfall at Stirling, 
Clonee, Co. Meath (height above sea level, 231 feet), was 
2.47 inches on 15 days. The heaviest day's fall was .32 inch 
on the 3rd. On the 30th .30 inch Avas recorded. No rain 
fell from the 10th to the 20th, inclusive. The rainfall of the 
first 6 months of 1916 at Clonee has been 18.90 inches on 
125 rain-days, compared with 12.06 inches on 85 days in the 
first six months of 1915 and 10.28 inches on 91 days in the 
corresponding period of 1914. 

At Cheeverstown, Clondalkin, Co. Dublin, Miss Mary Love 
recorded a rainfall of 2.64 inches on 16 days. The greatest 



140 



Sanitary and Meteorological K'oteS. 



falls in 24 hours at Cheeverstown were .65 inch on the 1 0th 
and .36 inch on the 30th. 

Mr. F. Dudley Joynt returns the rainfall at 89 Anglesea 
Road, Donnybrook, Dubhn, at 2.090 inches on 16 days, .630 
inch having been recorded on the 30th. The haH-year's fall 
was 16.245 inches on 114 days. 

Mr. Harold Fayle forwards the folloA\ing A\eather report for 
June from Rosedale, ShankiU, Dublin : — 



Mean corrected height of Barometer, - 

Highest corrected reading (16th, 8 hours) 

Lowest corrected reading (4th, 20 hours). 

Mean Dry-bulb Temperature, - 

Mean Wet-bulb Temperature, 

Mean Vapour Pressure, 

Mean Humidity, ... 

Mean Maximal Temperature, - 

Mean Minimal Temperature, - 

Arithmetical Mean Temperature, 

Highest Temperature in Screen (17th), 

Lowest Temperature in Screen (14th), 

Lowest Temperature on Grass (14tli), 

Nights of Ground Frosts 

Rainfall (on 16 clajs), - 

Greatest Daily Raiirfall (30th), 

Mean Amount of Cloud, 

Days of Clear Sky, 

Days of Overcast Sky, 

General Directions of Wind, - 



■ 29.945 inches. 

- 30.36 

- 29.30 
53.1°. 

- 50.3°. 
.331 inch. 

- 81 per cent. 

■ 60.0°. 
46.7°. 
53.4°. 
67°. 
39°. 

• 26°. 

4. 

1.91 inches. 

0.53 inch. 
68.5 per cent. 

2. 
14. 
W., N.W. 

During the six months ended June 30th, 1916, 18.46 inches 
of rain fell on 117 days at Rosedale. 

Writing from Belfort House, Dundrum, Co. Dubhn, Dr. 
Arthur S. Goff states that rain fell there on 19 days to the 
amount of 2.11 inches, the largest fall on any one day being 
.60 inch on the 30th. The air temperature ranged from 40° 
on the 7th to 77° on the 17th. The mean temperature in the 
shade was 55.4°. The half-year's rainfall was 19.24 inches 
on 125 days. Thunder and lightning occuiiod on the 9th. 

Mr. W. J. McCabe, on l)elialf of the Right Hon. L. Waldron, 
D.L., supplies tlio following record of the rainfall at Marino, 
Killincy : — Rahi fell on 15 days to the amount of 1.74 inches, 



Sanitary and Meteorological Notes. 14:1 

the maximal fall in 24 hours being .51 inch on the 30th. The 
average rainfall in June at Cloneevin, KiUiney, in the 24 years, 
188;5-1908, was 1.771 inches on 13.2 days. 

Dr. J. H. Armstrong reports that at Coolagad, Greystones, 
Co. Wicklow, the rainfall was 2.57 inches on 17 days. The 
heaviest rainfall in 24 hours was .60 inch on the 30th. 
Thunder, lightning, and a hail-shower occurred at 3 50 p.m. 
of the 2nd. Thiuider was also heard at 4 p.m. of the 6th, and 
at 12 45 p.m. of the 9th. Fog hung over the sandbanks 
throughout the 17th, and there was a sea fog at 8 p.m. of the 
28th. 

At Auburn, Gre^'stones, Co. Wicldow, Mrs. Sydney 
O'Sullivan measured 2.46 inches of rain on 15 days, .55 inch 
being recorded on the 30th. 

Dr. F. O'B. Kennedy reports that at the Roj-al National 
Hospital for Consumption for Ireland, Newcastle, Co. Wicklow, 
rain fell on 14 days to the amount of 2.52 inches, the maximal 
fall in 24 hours being .64 inch on the 30th. The mean 
temperature for the month was 53.5°, the extremes being 
—highest, 68° on the 17th ; lowest, 40° on the 8th. The 
mean maximal temperature was 59.1° ; the mean minimal 
temperature Avas 47.8°. The prevailing winds were N.W. 
and N. 

The Rev. Canon Arthur Wilson, M. A., reports a rainfall of 
2.77 inches on 15 daj's at the Rectory, Diunuanway, Co. Cork. 
The heaviest falls were .63 inch on the 21st and the same 
amount on the 30th. No rain fell from the 8th to the 19th 
except .01 inch on the 11th. N.W. and N.E. winds prevailed, 
and it was very cold for June, but the weather was warm from 
the 14th to the 19th. There were frequent frosts at night, 
but not severe enough to cut potatoes. The rainfall for the 
completed six months of 1916 amounts to 27.28 inches on 122 
days, compared with 28.45 inches on 105 days in 1915, 31.38 
inches on 106 days in 1914, 39.32 inches on 123 days in 
1913 — the average being 28.71 inches and 116 da3^s in the last 
10 years. 



PEEISCOPE. 

ACUTE DIABETES AND ACIDOSIS. 

Dr. Walter G. Smith, Physician to Sir Patrick Dun's Hos- 
pital, Dublin, reports in TJie Lancet for June 3, 1916, a 
remarkable case of acute diabetes in a boy aged 7 years, 
who had been apparently quite well up to Christmas-time, 
1915. The case afforded the Reporter an opportvuiity for a 
very close and searching inquiry, which he summarises in 
the following propositions: — 

1. There is no simple direct test for oxybutyric acid at our 
disposal. Its detection can be effected only indirectly. 
Barium oxybutyrate forms long needle-shaped crystals (W. 
Caldwell) which are doubly refracting. 2. Neither oxy- 
butyric acid nor acetone gives any colour reaction with ferric 
chloride. Oxybutyric acid has no reactions in common with 
acetoacetic acid. Hurtley's method for its quantitative 
determination by extraction with ether and estimation by 
titration and optical rotation is described in Pliinmer (Pract. 
Organic Chem., p. 597). 3. For acetoacetic acid three tests are 
availalile : — (a) Gerhardt's: Not very sensitive; hence much 
misapprehension. Failure of the ferric chloride reaction does 
not entitle one to state that acetoacetic acid is completely 
absent. (/;) Rothera's test: Reacts with both acetone and 
acetoacetic acid. The latter is moic sensitive to the test 
tlian acetone in the ratio 20: 1. One pait of acetoacetic acid 
in 400, 000 gives the reaction in ti\t' minutes, (r) Kiegler's 
test : Differentiates acetone and acetoacetic acid. jNlethod 
of applying the test: 10 c.c. of urine are acidified witli five 
drops of 30 per cent, acetic a'/id, and fi\c drops of liUgol's 
iodine sohition are added. Tliis juixluic is shaken with 
ti or 3 c.c. oi' chloroform. No colour appears if acetoacetic 
acid be present (Plinmier). 

CH3COCH2COOH + I2- CH3CO . CHI. COOH + HI. 
lodo-acetoacetic acid (colourless). 
I have no experience of Arnold's test (para-amino-aceto- 
phenone) and little of Hurtley's purple test (iso-nitroso- 
acetone). They arf more comj)hcated and appear to be 
scarcely necessai-y. IMinuncr, hf)\vever, considers tliat 
Hurtley's reaction is very useful for gauging tlic 
amount of acetoacetic acid in a solution or in urine. 



[ 



Periscope. 143 

4. Acetone does not respond to either Gerhardt's or 
Eiegler's test. Its reaction with Eothera's test is similar to 
that of acetoacetic acid, but is less sensitive. The sensitive- 
ness of Eothera's test is increased by the addition of a solid 
ammonium salt (sulphate or chloride). The best way 
of employing it is this : Over a layer of the salt the urine 
is floated, and then tested as usual with nitroprusside and 
ammonia. Dr. Smith can confinn the value of this modifica- 
tiou. He found that a specimen of diabetic urine preserved for 
nearly four weeks still gave a distinct red with FeCl3. When 
diluted to 1 in 10 it scarcely reacted to the iron test. It failed 
to respond to Lugol's test, or to Le Nobel's (Eothera's) test 
until layered over solid (NH4)o SO4, when a bright purple- 
red zone developed. It is stated in Neubauer-Huppert that ace- 
toacetic acid disappears from urine at latest in 48 hours. 5. 
The amount of acetoacetic acid in urine is usually consider- 
ably greater than that of acetone — viz., from 2 to 10 times 
as much (Plimmer). There are two soiu'ces of acetoacetic 
acid in the urine : (a) preformed ; (h) derived from intravesical 
decomposition of oxj'butyric acid. 6. There is no simple and 
reliable test at present known for the detection in urine of 
small amounts of acetone in association with acetoacetic acid. 
Many data published in connection with acetonuria ai-e 
vitiated by ignorance of this fact. Scott-\Yilson's method 
of detecting and estimating acetone alone by conversion into 
a keto-mercury-cyanide precipitate is described in Plimmer 
(p. 592). 7. Eothera's test differentiates acetone from 
creatinin. Creatinin reacts with sodiinn nitroprusside and 
either liquor potassae (sodae) or liquor ammoniae. Acetone 
reacts only with nitroprusside and liquor ammoniae. 8. The 
term " acetone bodies " (or, " acetonuria ") is not a happy 
one, for it lays stress on the least important member of the 
triad. Since acetone alone is not infrequently met with in 
urine, perhaps it would be well to indicate that fact by 
acetonuria, and to use the term acefouria for the cases in 
which acetoacetic acid occurs. 9. The theoi-y of " acidosis " 
is still incomplete. The modes of origin of " acetonuria " 
are complex, and are largely influenced by the amount of 
carbohydrate food assimilated. 10. For the solution of such 
difftcult problems the cooperation of clinical physicians and 
experts in organic chemistry is essential. 

In an " Appendix " to his communication. Dr. Smith gives 
the following examples of errors and inaccuracies culled from 
text-books on Medicine and on Urinary Analysis: — 

1. Acetone gives a red colour with ferric chloride. 
This error occurs in Fagge's " Practice of Medicine," 



] 44 Periscope. 

edited by Pye-Smith, 1888; and also in Roberts's 
" Treatise on"^ Urinary and Renal Diseases," fourth 
edition, 1885. Gerhardt's test for acetoacetic acid 
was described in 1865. 2. Other substances (than ace- 
toacetic acid)— e.g., formic, carbolic, and salicylic acids- 
give the same reaction in both fresh and previously boiled 
urine. For same read somewhat similar. No practised eye 
would confound the colours. 3. Both oxybutyric acid and 
acetoacetic acid react similarly with the ferric chloride test. 
This is not the case. 4. " Fehling's solution is reduced by 
acetone, but this test should be applied to the distillate from 
the urine." Acetone does not reduce the copper solution. 
5. Rothoi-a's nitroprusside test is true for acetone only. It 
is a much more sensitive test for acetoacetic acid. 6. INIany 
drugs i)r()duce temporary diabetes. For diahctes read gly- 
cosiiiia. 7. " Tiarge quantities of water are required (by the 
patient) to kee]) the sugar in solution, and for its excretion 
in the urine." (Ilucose is soluble in its own weight of water. 
The quantity of glucose in the blood of a severe case of dia- 
betes is a fraction of 1 per cent. 



ILKAL KINK. 

Mr. Foster (Ncir Zealand Medical Journal, Vol. XIV., 
No. 64) reports the case of a patient aged twenty-eight 
years, who had suffered from dull pain over his sacrum since 
he was eleven years oldj_ stooping made the pain worse, 
but it was relieved on lying down. He was always tired, and 
on lying down fell off asleep at once. When his work was 
done he wanted to go to bed, and was too tired for amuse- 
ments. He suffered from constipation since boyhood, but of 
late years his bowels were kept regular by aperients. To 
external examination no local tenderness on pressiu-e was 
found ; ilexion good ; reflexes normal ; .r-ray of bones normal. 
A bismuth meal showed a mass in the terminal extremity 
of the ileum and in the caecum, with kinking of the ileum 
close to its coecal entrance. Operation revealed marked signs 
of old standing inflanmiation of the ap))endix, with a shortened 
and adherent meso-appendix. A strong band of adhesions 
running from the ileum to the right iliac fossa, forming a 
marked V-shaped kink, was found about four or five inches 
from the c*cum. The band was cut throngli and the l<inlv 
reduced; the law pcvitoiical edges stitclnMl (>\cf, and ilic 
al)doiiien closed. The patii'ut made a good recovery ; i'i'suukmI 
his occupation; and now suffers no inconvenience. 



THE DUBLIN JOURNAL 



OF 



MEDICAL SCIENCE. 



SEPTEMBER 1, 1916. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. VIII. — Fractures aud Fracture Dislocations.^ By 
John S. M'Ardle, M.Ch. {Hon. Causa) E.U.I., 
F.E.U.I., F.R.C.S.I. ; Professor of Surgery, National 
University of Ireland; Senior Surgeon, St. Vincent's 
Hospital; Consulting Surgeon, National Hospital, 
Holies Street, and Children's Hospital, Temple Street, 
Dublin. (Illustrated.) 

{Continued from Tohimc CXLII, page 79.) 

I NOW come to deal with fractures of the upper end of the 
forearm bones. My first experience of such cases was a 
personal one, having sustained, through a riding acci- 
dent, a very complicated fracture-dislocation of the right 
elbow. In those days surgeons had not the great assist- 
ance of .r-ray prints, nor had plastic operations come 
into vogue. Nevertheless, Thomas, of Liverpool, with a 
patience which was characteristic of him, gave me a very 
useful arm, and in the weary months of treatment I saw 

» A Course of Lectures on Clinical Surgery delivered at St. Vincent's 
Hospital, Dublin. 

VOL. CXLII. — NO. 537, THIRD SERIES. L 



146 Fractures and Fracture Dislocations. 

niany instances of successful bone surgery which were an 
inspiration to nie. I learned from observing the methods 
of this master that no bone injury, however grave, should 
give rise to despair. His results later on heartened me 
much when dealing with a])])arently hopeless cases. 

The gravity of my own case was only brought home to 
my mind when T had a photograph of the joint taken 
within a few weeks of Rontgen's great discovery. 

When I entered on the study of surgery at St. 
Vincent's Hospital I liad the good fortune to be asso- 
ciated with the late Mr. O'Leary, the most brilliant 
diagnostician I ever met. His. comments, whenever a 
serious injury of the elbo^w was brought under his notice, 
interested me very much, and with his kind help I soon 
acquired a working knowledge of elbow-joint surgery. 

Before dealing with fractures of the olecranon, which 
will occupy our attention to-day, I wish to point out to 
you the landmarks which render differential diagnosis 
])ossible but not always easy. You have ample evidence 
in the wards even now as to the frequency with which 
dislocations have been treated as fractures. Plate VII., 
Fig. 18, is a good example of such a case, and when I tell 
you that it is ten months since the accident occurred, and 
that the limb was put up in an L-shaped splint for six 
weeks, you will understand what a very grave injustice 
this poor man suffered at the hands of the surgeon who 
first examined him. 

You will experience, as I do, how difficult it is to deter- 
mine the exact pathological condition in complicated in- 
juries of the joint under discussion. And so I want you to 
examine this well-developed and normal elbow. See, I 
mark the point of the acromion and the tip of each con- 
dyle. Now flex and extend the forearm and you find that 
the spot over the acroiuion moves evenly between the 
other two. Next place your thumb on the outer condyle 
;ni(i pronate and supinate the forearm and you will feel 
I lie head of the radius rotate on \\\o radial head of the 
hiiincius, showing its position to ho noi'mal. With the 



Mr. John S. M'Ardle. — Fracttins und Fracture Dislocations. 

PLATE VII. 




Fig. 18. 




I'K,. I'.i, 



^Ii;. John S. M "Audlk. — Fnicttircs diid l''rnciiiri I )isl(}C(il ions. 
PLATE \lll. 




Fro. 20. 




Fi(.. 21. 



By Mr. John S. M'Ardle. 147 

condyles in exact relation to the tip of the acioinion you 
may be satisfied that there is no dislocation. 

With the exception of complicated fracture disloca- 
tions, usually the result of direct violence, the diagnosis 
lies between a dislocation backwards of both bones of the 
forearm, as in the case now awaiting operation as shown 
above, and fracture above the condyles. 

While in fracture the normal relation of the surgical 
landmarks is maintained, in dislocation the tip of the ulna 
is carried backwards and upwards, and the head of the 
radius becomes so superficial that ail doubt is removed 
by the fact that you can feel the cupped head of the 
radius above and behind the outer condyle. 

Before the era of plastic bone surgery in the case of 
fracture of the olecranon union took place by dense 
fibrous material forming between the fragments, but at 
times a bony junction was obtained when the fracture 
was obhque, as in Plate VII., Fig. 19. 

In this case you will observe that the line of separation 
is oblique and extends down through the posterior ridge 
of the ulna. The upper fragment has been prevented 
from displacement upw^ards by the ulnar expansion of the 
triceps tendon. When I got this plate from Dr. Maurice 
Hayes I decided that splint support was all that was 
necessary. My justification for so acting is shown in 
Plate VIII., Fig. 20, taken twelve weeks after the accident. 
In all these cases early passive motion should be 
carried out, beginning from the fifth to the eighth day, 
the arm being rejilaced in splints after each seance. The 
position of semi-flexion is the best, and Callendar's splint 
is the most useful. 

When the fracture is transverse, and the ulnar expan- 
sion of the triceps is torn, a great gap separates the frag- 
ment, as in Plate VIII., Fig. 21. 

In this case there was ample evidence that the triceps 
tendon was completely gone, because the patient could not 
carry out extension of the forearm even to a slight degree. 
I, therefore determined on ())ien operation, and Plate IX., 



14ft Acnte Appnuh'ciiis irith Perifonitis. 

Fig. •2-2, shows how well the bones have been approximated 
by wiring. A word in passing as to wiring versus screw- 
ing. The former is slow and entails much manipulation, 
and requires a free opening of the joint. The latter is 
rapid, opening the joint can be avoided, and the patient 
has tlie use of the limb almost immediately, movement 
being allowed on the third day and full use of the joint in 
two to three weeks. At night it is wise in these cases to 
secure fixation of the joint by a Jones's elbow-splint, while 
in the daytime a leather sling is all that is necessary for 
the patient's comfort. Plate IX., Fig. 23, shows the 
result of screw fixation of the olecranon twelve weeks after 
operation. 

In this case an incision two inches long down to the 
attachment of the triceps, splitting the fibres thereof, and 
inserting a screw shown at Plate IX., Fig. 23, occupied 
only a few minutes. The patient left hospital on the 
fourth day, and within a fortnight he was back at his 
work. Plate X., Fig. 24, shows the drilling screw 
which I employ and the driver which renders its applica- 
tion easy. 

I have come to the conclusion that in transverse un- 
complicated fracture of the olecranon with wide separa- 
tion of the fragments a screw should be applied at once, 
and 1 look upon the treatment by splints in the light of 
modern advance as quite unsurgical, always supposing 
that you liave the necessary appliances and the surround- 
iuiis ritiiit. 



Art. IX. — Acute Appcmlicitis with Peritonitis : their 
Relation and Treatment.^ By John Weslfa' Long, 
:\r.I)., F.A.C.S., Greensboro', N. Carolina. 

TiiR Relation of Appendicitis to Peritonitis. 

Acute appendicitis should alwnvs !)(> liyplicuated with 
|)ontonitis, or, what is better, two hyphens (-=), making 
the algebraic sign of equation, since acute appendicitis 
continued equals peritonitis. They are as inseparable as 
» Head before tlic Nortli Carolina Metli<;al Society, April is, line. 



Mr. John S. M'Ardle. — Fractures and Fiutcturc Diftlocdfious. 

PLATE IX. 




Fig. 22. 




Fto. 2n. 



Me. John S. M'AitoLE. — Fractures and Fracfiirr Dislocations 




Fig. 24. 



By Dr. John Wesley Long. 149 

cause and eflect. While tlie latter does not always prove 
the presence of the former, the former rarely fails to pro- 
duce the latter. The relation between the two is so close 
that the one often overshadows the other. Patients are 
brought into the hos^Dital in the ambulance, with abdomen 
distended, rigid, tender, knees drawn up, frequent pulse, 
septic temperature, &c., with the diagnosis of "appen- 
dicitis." Strangely enough, the more serious lesion is 
overlooked in the presence of the initial appendicitis. I 
would not have you think for a moment that the appendix 
sliould be disregarded. Nay, verily, but I do desire to 
focus your attention upon the larger and more destructive 
phase of the subject. Appendicitis, whether acute or 
chronic, is, surgically speaking, a very simple problem; 
peritonitis is ever a grave menace to life. The one may be 
compared to the nuu'der of the Austrian Crown Prince ; 
the other is more like the resulting conflagration that has 
embroiled almost the entire world. 

It is not enough to say, " patients with acute appendi- 
citis should be operated upon before peritonitis develops." 
Even the most ignorant layman will admit so self- 
evident a proposition — after peritonitis is well under way 
and the patient is getting bad off. It is gratifying to note 
that the proportion of cases of appendicitis with peri- 
tonitis as its chief feature is less than in former years. I 
hasten to say that delay till peritonitis develops is not 
always due to inertia upon the part of the family physi- 
cian. Often he has to contend with the ignorance of the 
patient, the prejudice of the family, and the pernicious- 
ness of meddlesome neighbours. Nevertheless, it behoves 
us to take inventory of our knowledge concerning these 
desperate cases and establisli as nearly as may be possible 
well-defined rules for their management. 

While accumulated experience has crystallised into 
well-settled convictions concerning this subject there are 
yet many (juestions relating thereto that must be regarded 
as suh judice. Also, it must be confessed that the con- 
viction of to-dav may be the doubt of to-morrow. Hence, 



150 Acute Appendicitis with Peritonitis. 

we must ever maintain tlie attitude of the student. 
Another reason why a prudent man liesitates to recom- 
mend any special Hne of treatment is that the unthinking 
may imagine that the particular method advocated applies 
to all cases. Nothing could be further from the truth. 
The subject is so large that we will notice only certain 
aspects of it. 

THE TIME TO OPERATE. 

Jn deciding when to operate no hard and fast rules 
can be relied upon. One's surgical judgment is the safest 
guide. As a general proposition, a patient seen within the 
first twenty-four, forty-eight, or even seventy-two hours, 
should be operated upon promptly, whether it be daytime 
or night. You will not understand me to say that it is 
safe to wait the time limits just mentioned. I urge just 
the contrary. Every hour lessens with increasing rapidity 
the chances of recovery. Nor is it exactly correct to 
measure time by hours alone. The general morale of the 
patient nuist be considered. Can he withstand the added 
trauma of the operation plus the antesthetic? Is there 
some complication present that may be made worse by 
the operation? I lost an elderly man recently who was 
brought in early enough to come within the time limit. 
Operation was done at once, but the man died within 
twenty-four hours. His death was not due to appendicitis ; 
nor to peritonitis, but to nephritis, as was shown by scanty 
urine, casts, albumen, delirium and coma. Delay would 
in all ])robability have given him a better chance. Post- 
j)onement carries an extra hazard in children because 
their omentum is undeveloped, they stand starvation 
])oorly, and Xhc'w resistance is more rapidly broken down. 

LATE ()PI';i{A'l'IONS. 

Certain of these patients are seen too late for an early 
o|)erati()n. Their condition is always a dp])loral)le one 
iinilti|)jie(l ten-fold. ^I'hey require the most judicious 
li;in(lling. I'^iguratively, they are walking over thin ice. 



By Dr. John Wesley Lonc. 151 

The least jar, as from operation, anaesthetic, purgation, 
or even rough palpation, may cause them to break 
through. 

What, then, shall we do? Ochsner has taught us some 
invaluable lessons touching the management of such 
cases. In the first place, let me urge you to neither 
purge nor feed. There is nothing so harmful in the 
presence of peritonitis as purgation and feeding. Both 
increase the gas in the alimentary canal, gas promotes 
peristalsis, peristalsis spreads infection. These patients 
should be propped up, either by elevating the head of the 
bed or the body of the patient. The position must be a 
comfortable one, else it is wiser to leave the patient prone. 
He should be sustained by small nutrient enemas and 
hypodermoclysis or glucose in salt solution or sterile 
water. The ]\Iurphy drip method is applicable here. If 
nauseated or if the stomach is dilated, frequent gastric 
lavage is an invaluable remedy. If internes would carry a 
stomach tube about their necks instead of a shiny cow- 
horn-shaped stethoscope in their outside coat pocket they 
might be of more service to their patients. In the hos- 
pital where I work the nurses are taught to do lavage. 
They frequently save life thereby. 

Operation is best done w^hen the peritonitis is receding 
rather than spreading. The most gentle manipulation is 
demanded. In some instances the abdomen may be 
opened by a puncture incision, using a local anaesthetic 
or a few whiffs of gas. Just a tiny nick through which to 
insert a rubber tube is sufficient. It is often best to do 
this without removing the patient from the bed. The 
tendency among surgeons to-day is to not delay unduly 
opening the abdomen even in the worst of late cases. 

Some very wise surgeons refuse to remove the ap- 
pendix, preferring rather to do so later. Certainly, should 
the patient survive, the appendix can be removed with 
greater safety subsequently. However, I have always felt 
that when more than a puncture wound is made and the 
appendix can be easily removed it is well to do so, other- 



152 Acute Appendicitis ivitJi Peritonitis. 

wise leave it alone. Here, again, the general condition 
of the patient must be carefully studied. It is as impor- 
tant to know what kind of patient the disease has, as the 
kind of disease the patient has. 



THE ANESTHESIA. 

Every factor brought into use in abdominal surgery 
assumes added importance when applied to appendicitis 
with peritonitis. The more severe the case the greater 
the influence of each factor. This is particularly true of 
the anaesthesia. Nothing connected with abdominal 
surgery is so barbarously done. Go where you will, in the 
clinics of this country or of Europe, the anaesthesias one 
sees make a conscientious man shudder. Crile has done 
more than anyone else to teach us the truth regarding 
anaesthetics. Whether or not his anoci-association pro- 
duces less shock than other methods may be questioned, 
but most assuredly the principles he lays down are cor- 
rect. Under no other circumstances does a faulty 
anaesthesia produce more disastrous results than in 
patients septic from acute infectious appendicitis with 
peritonitis. Whether one uses ether, gas, or a local 
ana'sthetic he cannot walk too delicately. 

It gives me great pleasure to say, based upon a some- 
what extensive observation both at home and abroad, 
that America, the birth-place of ana'sthesia, is leading" 
the world in the matter of safer aucosthesia. The indict- 
ment brought to-day is fast losing its significance. Pro- 
gress is noted in the abolition of chloroform, the open- 
drop method of giving ether so widely popularised by the 
Mayo Clinic, the pharyngeal and intra-tracheal methods, 
the gas-oxygen anaesthesia, and the more extensive use of 
local ana'sthetics. But, above all else, the improvement 
consists in em|)loying" trained anirsthetists. No ana^sthe- 
tiscr ("in be ciillcd an expert who sj)ends a good part of 
his time talking v\ith those about him, or watching the 
surgeon to see how he may do the operation himself, the 



Dr. J. \\'f,slf,', Lii.Nd — Ariitr Appiiiiliciti.'i iritli J'critoiiifi. 
IT.ATK A 



A- 




Hfc;>^-n. >; 



[;;.;.• 




L^-rnpi'^ 



By Dr. John Wesley Long. 163 

tiist cliance he gets. A nurse with proper qualifications 
makes a very efficient anaesthetist. 

THE INCISION. 

The incision is a matter of considerable moment. In 
chronic conditions one may employ almost any incision 
he fancies. In acute septic abdominal diseases it is im- 
perative that it gives the readiest access to the lesion. I 
have tried every kind of incision — the mid-line, straight 
rectus, transverse, semilunar and oblique. I finally 
settled down to the last as being the most serviceable. 

The incision employed is essentially that of McBurney, 
though considerably amplified. The illustration (Plate A) 
shows clearly its location and successive steps. Note its 
relation to the umbilicus, iliac crest and pelvic |X)rtion of the 
abdomen. The skin and fat have been incised and drawn 
apart and the fibres of the external oblique separated. 
This gives a wide exposure of the deeper layers of the 
abdominal wall. One can now determine by inspection 
and palpation the intra-abdominal conditions far better 
than was possible from the outside. This method of ex- 
amining the abdomen I have not seen mentioned. Having 
confirmed the pre-operative diagnosis, it is easy to decide 
whether to enter the abdomen high or low, close to or 
through the rectus sheath, or nearer to the iliac crest. 

The muscular portion of the internal oblique is opened 
with forceps. This brings us to the transversalis fascia 
which is incised in line with the internal oblique. The 
fascia tends to contract, hence it is well to grasp its edges 
with forceps as appears in the illustration. In the sub- 
sequent closure care should be taken to suture the trans- 
versalis since it is probably the best safeguard against 
hernia. The peritoneum may be opened in any direction 
desired. The oblique incision brings one directly into the 
right iliac fossa. If the appendix be "at home " it is 
easy to find and remove. Should it be hanging over the 
brim, flirting with the ovaries, or wholly within the 
pelvis or located post-csecal, or should it be of the un- 
descended variety, it is still comparatively easy to reach. 



154 Acute Appendicitis with Peritonitis. 

The lower end of the incision which Hes over the pelvis 
may be lengthened if desired. In doing so no muscular 
fibres should be cut. The sheath of the rectus is entered 
and opened downward, pushing the muscle aside. Some 
times only the skin and fat incision need be made longer. 
Through the remaining layers of the abdominal wall a 
short transverse incision can be made for pelvic manipu- 
lation or a puncture done through whicii to introduce a 
drain. The same is essentially true of the upper end of 
the incision when one wishes to go higher in the abdomen, 
either for exploration or drainage. 

The closure of an incision made after this manner is 
comparatively easy. But the great advantage is that it 
leaves the abdominal wall strong, even though two or 
three drains are employed, as shown in the illustration. 
While one would rather have a hernia than a hearse 
follow his operations he naturally prefers neither. 

DRAINAGE. 

I approach this part of the subject with some trepida- 
tion. First, because I am addressing an audience reputed 
for its conservatism as well as for its wisdom ; and, second, 
because I stand in the presence of perhaps the greatest 
surgical authority in the world, who has kindly consented 
to discuss this paper. 

There is no practice in surgery that is more firmly 
established than is drainage in septic cases. In fact, 
drainage is the si)ie qua non in most instances. 13efore 
the coming of the abdominal surgeon, nature drained 
many of these patients by rujjturing the abscess into the 
bowel. The septic pus lying against the intestine softened 
and weakened the tissues till finally the pressure caused 
tlieni to yield and the pus would escape into the gut. 
Shortly afterwards a ])int or more of bloody pus would 
pass per rectum. When the doctor paid his next visit the 
patient would be sitting up in bed hallooing for something 
to eat. Thus nature cured the patient by drainage. 



By Dr. John Wesley Long. 155 

In tlie matter of drainage the peritoneum naturally 
plays an important role. The first thing it does when in- 
vaded by infection is to pour forth an abundance of serum. 
]t is easy enough to demonstrate the presence of peri- 
toneal fluid by catheterising the pelvis through the 
abdominal incision. A glass catheter gently slipped to 
the bottom of the cul-de-sac does no trauma, nor is it 
likely to spread infection. It is not unusual to find the 
pelvis half -full to running over with serum within twelve 
to twenty-four hours of the initial symptom. The fluid 
found varies from a light straw-coloured serum to one of 
greater or less turbidity. It often resembles pus due to 
the superabundance of white blood cells. The peritoneal 
fluid is the patient's first line of defence, zealously try- 
ing to prevent systemic invasion. To mop it out or drain 
it away is to rob the patient of his best protection. The 
earlier operators lost many of these patients because they 
not only drained but washed out the abdomen with large 
quantities of salt solution. It is perhaps fortunate that 
only a small portion of peritoneal fluid will escape through 
drains. Indeed, many surgeons go so far as to say the 
peritoneum cannot be drained for more than a few hours 
at the farthest, since the rapid formation of adhesions 
precludes the possibility of long-continued drainage. 
Speaking of adhesions, what an irreparable injury the 
surgeon does his patient whose abdomen he drains with- 
out sufficient cause ! 

But let us turn for a moment to those cases which all 
agree should be drained. In what way does drainage benefit 
the patient? The answer is twofold. First, it removes 
at once the excess of septic fluid. The second benefit is 
quite as important — namely it disturbs the pathological 
equilibrium. The incision plus the escape of septic fluid 
relieves the tension and starts the lymphatic current out- 
ward rather than toward the diaphragm, while intra- 
abdominal pressure promotes exosmosis. The peritoneum 
is thereby given the opportunity to dilute and absorb 
more slowly the infection lodged in its innumerable re- 



156 Acute Appendicitis irith Peritonitis. 

cesses. The result is that the patient is not overwhelmed 
by the toxins. How else can you explain the recovery 
in those fulminate cases which are cured by simply 
making" a button-hole incision and sticking in a small 
drain ? 

Nor is this all the peritoneum does. Secondary 
abscesses, which so often occur notwithstanding the 
abdomen has been drained after the most approved 
fashion, are evidence that the peritoneum continues to 
safeguard the patient. Such an abscess means that the 
peritoneum, failing to absorb all of the infection, rallies its 
resources and circumscribes the resulting pus by the for- 
mation of adhesions. In other words, the peritoneum 
does most of the work while the surgeon gets the credit 
for it. 

A careful study of the subject forces us to the conclu- 
sion that w4hle in the vast majority of instances drainage 
should be employed, yet under certain circumstances the 
peritoneum is far more able to cope with infection alone, 
and should not be handicapped by the presence of a 
foreign body in the sliape of a drain. 

Were vou to ask me the dividing line between drainage 
and non-drainage cases, I would have to confess that the 
distinction is not yet clearly defined. I know this — I have 
drained many patients that I am now convinced need not 
have been drained; 1 have omitted drainage in only two, 
and later regretted it. My record shows twenty-nine 
patients having acute appendicitis with more or less peri- 
tonitis and fluid in their abdomen in whom no drainage 
was employed, and all made a perfect recovery. Wliile 
writing this paper T operated upon a young man whose 
pelvis was fiil! of creamy-looking serum. 'Vhv abdomen 
was closed and he made a normal recovery. The same is 
true of a young lady with hoi- pelvis and lower abdomen 
full of straw-coloured sciiun. A paticiil Udi drained re- 
covers niiicli nioiv, smoothly than w hen drained. 

] recognise that this {)ractice is debatable ground. It 
is the advance firing line of abdominal surgery. In the 



By Dr. Jc^hn Wesley Long. 157 

solution of the problem the clinical surgeon and patholo- 
gist must work hand-in-hand. Mv own observations are 
being cheeked up by the laboratory findings. 

The propriety of draining having" been determined 
upon, the next question is as to the material that should 
be employed. I have practically abandoned everything 
else for soft rubber tubing witli or without a wuck and the 
so-called "cigarette." In wide open woimds gauze is some- 
times placed superficially. When it is necessary to pack 
a bleeding point gauze may be used to advantage. That 
portion of the gauze above the bleeding area should be 
surrounded with rubber tissue, which renders it easier to 
remove. 

In placing drains several essentials should be borne in 
mind. First, the drain should reach the most dependent 
portion of the infected area, whether it be the cul-de-sac, 
the kidney pouch or elsewhere. Secondary abscesses are 
often best treated by draining per vaginam, occasionally 
per rectum. When placed in these latter situations 
gravity aids capillarity. 1 recently drained such an 
abscess through the vagina, occurring in a lady eighty- 
two years of age. Second, it is imperative that drains do 
not rest against blood-vessels. The same is true to a less 
degree of the bladder and intestines. I lost a patient in 
my earlier experience from hemorrhage of the iliac 
vessels due to pressure necrosis caused by the drain. 
Haemorrhage from the deep epigastrics is often attribut- 
able to the same cause. The third item is to begin re- 
moving the drains early, usually at the first dressing on 
the day following the operation. It is good practice to 
gently loosen the drain ana clip off an inch or two daily. 
The more drains one uses the sooner some of them should 
be removed. 

RESUME. 

With the exception of the wider utilisation of the 
oblique incision, the method of checking up the dia- 
gnosis after partially opening the abdominal wall, and not 



158 Dia(inof!if! in IJvciiis. 

draining" certain cases, there is nothing especially new in 
the suggestions herein offered. Their vahie consists 
largely in the fact that they have been systematically 
tried out through many years of handling a rather large 
number of cases of appendicitis with peritonitis ; they 
therefore carry the endorsement of experience. 



Art. X. — Diagnosis in Uveitis.^ By Euphan Maxwell, 
M.B., Univ. Dubl. ; F.E.C.S.I.; Assistant Surgeon, 
Eoyal Victoria Eye and Ear Hospital, Dublin. 

{Continued from Volume CXLII, page 110.) 

4. Spirochaete pallida. 
The material eraploj^ed in the following experiments was 
kindly procured for me by Dr. Meldon. He selected known 
syphilitic cases with vulvar condylomata and scanty discharge. 
By swabbing a condyloma with absolute alcohol, he killed 
surface organisms, and in most instances obtained a watery 
exudate. This pipetted into warm saline was ready for injec- 
tion. Evidence of the presence of the Spirochaete pallida 
in the exudate was not visually confirmed in any of the experi- 
ments. 

1th Experiment. 

14.10.15. — 0. D. rabbit No. 7, injected syph. exudate. 
16.10.15.— 0. D. iritis. 

29.10.15. — Aq. h. O. D. examined with syph. and tubercular 
antigens. 

sy. a. tb. a. 
J?esM/« ;— Aq. h. 0. D. undil. +2 +i 

,, Aq. h. control ^-^ 

Hth Experiment. 

27.1.16. — O. D. rabbit No. 10, injected syph. exudate. 
9.2.16.— O. 1). mild iritis. 

Aq. h. (). 1). examined witl\ syph. and tb. 
antigens. 

Result : — Negative. 

» Mary I^ouiKa I'rciiticf Moiitgnnicrv Lc^'turc, dclivorofl in tlio 
School of Physic in Ireland, on Frithiy, June 2:5, HMC. 



By Dr. Eri'iiw Maxwell. 159 

1.3.16. — 0. D. quiet — post, synechise. 

Aq. h. O. D. and blood examined with syph- 
and staphylococcal antigens. 

sy. a. staph, a. 
BesuU ;— Aq. h. O. D. . — — 

Bl. 1 in 100 (not 

tested beyond) -f^ — 

19.4.16.— Aq. h. 0. D. and blood examined with syph. and 
diphtheritic antigens. 

sy. a. diph. a. 
BesvU .— Aq. h. 0. D. • — — 

Bl. 1 in 5 . . +^ +^ 

1 in 10 . . -f 1 _}.3 

1 in 100 . . — — 

In this experiment the blood was examined on two different 
occasions with syph. antigen, before the intraocular injection, 
and found negative. This is a necessary preliminary, as 
normal rabbit blood in low dilutions frequently inhibits com- 
plement in the presence of syph. antigen. 

9th Experiment. 
8.3.16. — 0. S. rabbit No. 15. injected syph. exudate. 
12.3.16.— 0. S. acute iritis. 

22.3.16. — Aq. h. 0. S. and blood examined with syph. and 
tb. antigens. 

sy. a. tb. a. 
Fesult .— Aq. h. O. S. dil. 1 in 4 -fi +i 
Bl. btw. 1 in 20 
and 1 in 160 . — _ 
Further examination unsuccessful oAving to clotting in 
tubes of aq. h. after addition of complement. 

10th Experiment. 
26.5.16. — 0. S. rabbit No. 16, injected syph. exudate. 
29.5.16. — O. S. — panophthalmitis rendered A\ithdrawal of 
aq. h. impossible. 

5. Tubercle Bacillus. 
11^^ Experiment. 
27.10.15.— 0. D. rabbit No. 8, injected bovine tb., heated i 
hour at 51° C. 



160 Dinqnosis in Uveitis. 

1.11.15. — 0. D. mild iritis. Second similar injection. 
4.11.15. — 0. D. acute iritis. 
25. 11 . 15. — Aq. h. O. D. examined with tb. and syph. antigens. 

tb. a, sy. a. 
Result:— Aq. h. 0. D. imdil. +3 +2 

13.12.15. — O. D. seclusio pupillae — deep ant. chamber — -no 
external congestion. 

Aq. h. 0. U. examined Avith tb. and staph, antigens. 
Result : — tb. a. st. a. 



Aq. h. 0. D., 1 in 5 . 


• +' 


„ 1 in 10 . 


• +' 


Aq. h. 0. S. undil. . 


+ ' 



not 

tested 

6.1. 16. — Aq. h. 0. D. examined with tb. and syph. antigens. 

Result :^ tb. a. syph. a. 

Aq. h. 0. D. undil. . . +3 — 

15.3.16. — Aq, h. 0. D. and blood examined with tb. and 

diphtheritic antigens. 

Result : — tb. a. diph. a. 

Aq. h. 0. D. dil., 1 in5 . +3 +3 

1 in 20 . — — 

Blood dil, 1 in 10 . +^ + =< 

,, ,, 1 in 50 . — — 

Further examinations of aqueous humour and blood showed 
no specific fixation of complement in presence of tubercular 
antigen. 

I2th Experiment. 
19.11.15. — O. D. rabbit No. 9, injected human tubercule 

bacilli. 
22 . 1 1 . 15.— 0. D. acute iritis. 
1.12.15 — Aq. h. O. D. examined Avith tb. and syphilitic 
antigens. 

tb. a. sy. a. 
Result :—Aq. h. 0. J), undil. -\-^ +1 

13.12.15. — 0. D. acute secondary glaucoma. 

Aq. h. 0. U. examined with tb. and staphylococcal 
antigens. 
Result : — tb. a. staph, a. 

Aq. h. O. D. undil. . . -|-3 — 



1 in 10 


• +' 


— 


Aq. h. 0. 8. undil. . 


— 


not 
tested 



By Dr. Etphan Maxwell. 161 

Passing to the second series of experiments, it is obvious that 
the detection of amboceptor in higher dilutions of aq. h. than 
of blood serum would demonstrate its local production, or local 
concentration. None of my previous experiments, in which 
both blood and aq. were examined, giving examples of this, I 
determined to make the following tests. Causing a general 
immunity in a rabbit with organism A., and an intraocular 
immunity with organism B., I examined blood and aq. for 
amboceptor A. and B. If amboceptor B. appeared in a higher 
aq. h. dilution proportionately to the blood serum than ambo- 
ceptor A., it would be suggestive of a local production of B., or 
its greater power of penetration through a ciliary filter inflamed 
by its own antigen : in either case an aid to local diagnosis. 
In most of the cases the aq. h. of the sound eye was also 
examined, it being quite conceivable that a local uveal pro^ 
duction of amboceptor B. might take place in both eyes. 

13th Experiment. 
12.1.16-7.2.16. — -Rabbit No. 11 received five intravenous 
injections of staph, aureus — lowest dose 50 m. 
bact., highest dose 1,-500 m. 
14.2.16. — Symptoms of general septicaemia. 
17.2.16. — 0. D. injected 3 m. diphtheroid bacilli, heated 

half an hour at 50° C. 
18.2.16.— 0. D. iritis. 

21.2.16. — Aq. h. O. U. and blood examined with staph, and 
diph. antigens. 
Results : — 
Aq. h. 0. D. undil. — unsatisfactory controls. 

staph, a. diph. a. 
„ 1 in 5 to 1 in 100 — — 

„ 0. S. nndU. . 
„ 1 in 2 
Blood 1 in 50 . 
„ 1 in 100 
„ 1 in 300 
*9.3.16. — Same fluids re-inactivated and examined. 

Result : — staph, a. diph. a. 

Aq. h. 0. D. 1 in 5 . . — +3 

„ 1 in 10 . . — — 

* Proportion of diph. amboceptor in aq. h, and blood lies between 1 in 1 1 
and 1 in 39. 



• +^ 


+^ 


'• +' 


+■' 


. +' 


— 


— 


— 



162 Diagnosis in Uveitis 

Blood 



1 in 100 


. +' 


+' 


1 in 200 


. +' 


— 


1 in 400 


. 4-^ 


— 


1 in 800 


— 


— 



lUh Experiment. 

21.1.16-21.2.16. — Rabbit No. 12 received 5 intravenous 

injections of diph. bac. — lowest dose, .1 of 5 cos. 

emulsion over-night serum slope ; highest dose, 

1 cc. of same. 
17.2.16. — 0. D. injected 10 m. staph, aur., heated half an 

hour at 50° C. 
23.2.16. — Condition of O. D. — very acute iritis. 

Aq. h. 0. D. and blood examined with staph. 

and diph. antigen. 

Aq. h. examination of no value owing to an 

admixture of blood on withdrawal. 

15^^ Experiment. 

28.2.16-27.3.16.— Rabbit No. 13 received five intravenous 
injections of diph. bac. — lowest dose, .2 of 5 ccs. 
emulsion over-night serum slope, heated 65° C, 
I hour ; highest dose, .5 cc. ditto, unheated. 
27.3.16 — 0. D. injected .1 of 10 ccs. emulsion staph, aur. 
over-night agar slope, heated 65° C. half an hour. 
5.4.16. — 0. D. well developed iritis. 

5.4.16. — Aq. h. 0. D. and blood examined with staph, 
and diph. antigens. 

Result : — staph, a. diph. a. 

Aq. h. 0. D. 1 in 5 . . — +i 

1 in 10 . . — — 

Blood lin 10 . . — -\-^ 

1 in 100 . — +1 

(Not tested beyond). 

10. 4. 16 — O. D. injected .1 staph, emulsion (see above), 
heated 60° C. half an hour. 

Aq. h. 0. U. and blood examined with staph, 
and diph. antigens. 



By Dr. Euphan Maxwell. 163 

Result : — staph, a. diph. a. 

Aq. h. 0. D. iindil. . . — +3 

1 in 10 . . — — 

,, 0. S. undil. (not 

tested beyond) . — -f.^ 

Blood 1 in 5 . . . -fi _(_3 

„ 1 in 10 . . . — -1-3 

„ 1 in 100 . . — -t-3 

(not tested beyond). 
*19.4. 16. — Aq. h. O. U. and blood examined. Examination of 
aq. h. 0. D. useless owing to admixture of blood. 
Result . — staph, a. diph. a. 

Aq. h. 0. S. undil. . . +2 _^3 

„ 1 in 5 . 
Blood 1 in 10 . 
„ 1 in 50 . 
„ 1 in 100 

(not tested beyond). 



_^2 _^3 



16^A Experiment. 
9.3.16-27.3.16. — Rabbit No. 14 received four intravenous 
injections of staph, aur. — lowest dose, .1 of 
10 CCS. emulsion over-night agar slope, heated 
68° C. three quarters of an hour ; highest dose, 
ditto, heated 62° C. half an hour. 
27.3.16. — 0. D. injected .1 of 5 ccs. emulsion over-night 
serum slope diph. bac, heated 65° C. quarter of 
an hour. 

5.4.16. — Condition of 0. D. acute iritis. 

Aq. h. 0. D. and blood examined. 

Result : — staph, a. diph. a. 



Aq. h. 1 in 5 . 


+ ' 


„ 1 in 10 . 


+ ' 


(not tested beyond) 




Blood 1 in 10 . 


+ ' 


„ 1 in 100 


V 


(not tested beyond). 





* Proportion of diph. amboceptor in uninfected aq. h. and blood between 
1 in 25 to 1 in 100 or less (compare experiment 13) ; of staph, ambo, 1 in 3 
to 1 in 49. 



164 



Diagnosis in Uveitis. 



10.4. 


16.- 


-Aq. h. 0. U. and blood examined 
Result : — 


• 








Aq. h. 0. S. in this and subsequent examina- 






tions negative with both antigens. 








s 


taph. a. 


diph. a 






Aq. h. 0. D. 1 in 20 . 


+ ' 


+ ' 






(not tested beyond) 










Blood 1 in 10 . 


+ ' 


+' 






„ 1 in 50 . 


+ ' 


— 






„ 1 in 100 


— 


— 


*19.4. 


16.- 


— Aq. h. and blood examined. 
Result : — 










s 


taph. a. 


diph. a 






Aq. h. 0. D. 1 in 10 . 


+ ' 


+ ' 






1 in 20 . 


— 


+ ' 






1 in 50 . 


— 


— 






Blood 1 in 10 . 


+ ' 


+ ' 






1 in 50 . 


+ ' 


— 






1 in 100 


• +' 


— 






(not tested beyond). 






11.5 


.16.- 


— Aq. h. and blood examined. 










Result : — s 


staph, a 


diph. a 






Aq. h. 0. D. 1 in 10 . 


• +' 


+ ' 






1 in 50 . 


. — 


— 






Blood 1 in 40 . 


• +' 


+ ' 






1 in 100 


— 


— 



llth Experiment. 
12.5. 16. — 0. D. rabbit No. 17, injected .2 of 10 cos. emulsion 

24 hour agar slope staph, aur., heated 63° C. 

haK an hour. Intravenous injection .01 of 

10 CCS. ditto B. coli, heated as above. 
13.5.16.— 0. D. mild iritis. 
17.5.15. — O. D. injected .15 of 5 ccs. ditto, staph, aur. 

Intravenous injection .015 of 10 ccs. ditto bac. 

coli, treated as on 12 . 5 . 16. 
23.5. 16. — 0. D. injected .1 of 3 ccs. ditto staph, aur., heated 

60° C. half an hour. Intravenous injection 

.2 of 3 ccs. ditto B. coli, heated 60° C. half an 

hour. 

♦ Proportion of staph, a. in aq. li. and blood between 1 in 4 to 1 in 5 
( probably lower) ; proportion of (lijih. a. in aq. h. and blood between 1 in 2 
and 1 in 3 or higher (compare e.\perimcnt 15). 



By Dr. ErpiiAN Maxwell. 16^ 

25.5.16. 



*31.5.16.- 



7.6.16. 



-0. 


D. acute iritis. 




Aq. h. 0. D. and blood examined. 




Eesnlt :— 




Aq. h. control in lower dilutions inhibiting 




complement. 




staph, a. coli a. 




Aq. h. Iin20 ... — +» 




(not tested beyond) 




Blood control undil. inhibiting complement. 




staph, a. coli a. 




„ 1 in 50 . . . — +3 




(not tested beyond). 


Aq 


. h. 0. D. and blood examined. 




Result : — staph, a. coli a. 




Aq. 0. D. 1 in 2 . . — -\-^ 




1 in 80 . . — +" 




1 in 200 . . — +2 




(not tested beyond) 




Blood 1 in 5 . . — -f' 




1 in 500 . . — +3 




(not tested beyond). 


0. 


D. acute secondary glaucoma. 


Aq, 


, h. and blood examined. 




Result : — 




Aq. h. controls inhibiting complement. 




stajah. a. coli a. 




Blood 1 in 10 . . . — +^ 




„ 1 in 100 . — +3 




„ 1 in 1,800 . . ~ +2 




(not tested beyond). 



I8th Experiment. 
12.5.16. — 0. D. rabbit No. 18, injected .15 of 10 cos. emulsion 
agar slope (over-night) b. coli, heated 63° C. 
half an hour. 

Intravenous injection .2 of 10 ccs. emulsion 
agar slope (over-night) st. aureus, heated 63° C. 
half an hour. 

* Proportion of coli amboceptor in aq. li. and blood between 1 in 6 and 
1 in 7. 



166 Diagnosis in Uveitis. 

13.5.16. — 0. D. acute iritis. 

17.5.16. — 0. D. injection .15 of 5 ccs. ditto B. coli. Intra- 
venous injection of .15 of 10 ccs. ditto staph, 
aureus. 

23.5.16. — 0. D. injection .15 of 3 ccs. ditto B. coli, heated 
half an hour 60° C. Intravenous injection .2 of 
3 ccs. ditto st. aureus, heated half an hour 60° C. 



*31.5.16.- 


-Aq. 


h. 0. D. and blood examined. 








Result : — 


staph, a. 


coU a. 






Aq. h. 1 in 2 . 


. — 


+ ' 






„ 1 in 40 . 


, — 


+ ' 






„ 1 in 80 . 


— 


— 






Blood 1 in 5 . 


, — 


+ ' 






„ 1 in 120 


. — 


+' 






„ 1 in 500 


. — 


— 


6.6.16.- 


-Aq. 


h. 0. D. and blood examined. 








Result : — 


staph, a. 


coli a. 






Aq. h. 1 in 2 . 


. — 


+ ' 






„ 1 in 8 . 


. — 


+ ' 






„ 1 in 200 


. — 


+' 






(not tested beyond) 










Blood 1 in 10 . . 


• +^- 


+' 






„ 1 in 100 


. — 


+' 






„ 1 in 180 


— 


— 



15.6.16. — Aq. h. 0. S. at various dilutions neg. with both 
ants. 

19^^ Experiment. 

3.6. 16. — 0. D. rabbit No. 19, injected .1 of 10 ccs. emulsion 
agar slope (48 hours) B. coli, heated 60° C. 
half an hour. Intravenous injection .1 of 10 ccs. 
ditto st. aureus, heated 54° C. half an hour. 

7.6.16. — 0. D., injected .1 cc. B. coli (see above). Intra- 
venous injection .1 cc. st. aur. (see above). 

* Projiortion of coli aml)occptor in aq. h. and blood between 1 in 3 to 
about 1 in 5 (compare experiment 17). 



By Dr. Euphan Maxwell. 



167 



*14.6.16.- — O. D. very acute iritis. 

Aq. h. O. U. and blood examined. 

Result : — staph a. coli a. 

Aq. h. 1 in 30 . . . — +3 

„ 1 in 90 . . . — — 

Blood 1 in 30 . . . -j-i +2 

1 in 60 . . . — — 

t20.6.16. — Aq. h. O. U. and blood examined. 



Result : — 

Aq. h. 0. D. 1 in 4 
„ 1 in 32 
„ lin96 
,, 0. S. undil. 
„ 1 in 5 
„ 1 in 10 
Blood 1 in 5 
„ 1 in 30 . 



staph, a. coli a. 



+ ' 



+ ' 



20^^ Experiment. 

3.6.16. — 0. D. rabbit No. 20, injected .1 cc. st. aureus 
(see experiment 19). Intravenous injection 1 
cc. B. coli (see experiment 19). 
7.6.16. — Above injections repeated. 

8.6.16. — 0. D. ant. ch. full of exudate^no aq. h. could be 
withdrawn. 
J20.6.16. — Aq. h. 0. S. and blood examined. 

Result : — staph, a. coli a 

Aq. h. 0. S. undil. 



+ " 



Excluding the syphilitic cases, in which the nature of 
the infection was not definitely ascertained, the following 

* Proportion of coli amboceptor in aq. h. and blood higher than 1 in 2 
(compare experiment 17). 

t Proportion of coli amboceptor in uninfected aq, h. and blood between 
1 in 2 and 1 in 6 (not lower). 

J Proportion of coli amboceptor in uninfected aq h. and blood between 
1 in 4 to 1 in 24 (compare experiment ID). 



J5 


„ lin2 


55 


„ 1 in 5 


ooc 


1 1 in 10 . 


)5 


1 in 50 . 



168 



Diagnosis in Uveitis. 



Table groups together the above results. The table also 
excludes those cases in which, from any cause, the results 
were not satisfactor}'. 



Nature of Experiment 


No. 

of 

Cases 


Positive 
Result 
demon- 
strated 


Positive 

Result 

indicated 


In- 
definite 
Result 


Nega- 
tive 
Result 


Aq. h. examined for ambo. pro- 
duced in response to eye infec- 
tion ..... 


12 


8a 


1 


_ 


36 


Blood examined for ambo. pro- 
duced in response to eye infec- 
tion ..... 


10 


6 


1 


_ 


36 


Aq. h. examined for absolute pre- 1 
ponderance of ambo. produced ' 
in response to eye infec- ; 
tion, in cases of co-existing 
general infection . . .17 


4c 






1 

! 

3c 


Aq. h. examined for relative pre- 
ponderance of ditto . . 7 


2 


3 2d 


— 



a One of these refers to an uninfected aq. h. in a case where 
the infected could not be withdraAvn. 

b These three cases are identical. 

c The four positive cases are those in which the more active 
amboceptor-producing organism was employed, the three 
negative those in which the weaker was employed. This 
result without this information would tend to be misleading. 

d These cases are indefinite, because no amboceptor being 
detected in the aq. h., the proportion in aq. h. and blood could 
not be estimated. It should be noted that in one of these 
cases the amboceptor was also absent in the blood, and in the 
other was detected only at a low dilution. 

SrMM.\RY OK Conclusions. 
1. These exj)erinients demonstrate the formation of 
an amboceptor, produced in resjionse to an intraocular 
infection, to be mainly due to general cellular activity : that, 
therefore, in the majority of cases of uveitis, the examina- 
tion of the aq.h. by the " fixation complement " method 
has no practical diagnostic value not also possessed by a 
similar examination of the blood. 



By Dr. IiJuphan Maxwell. IGO 

•2. These experiments indicate in cases of an intra- 
ocular inflammation co-existing with some other infection 
elsewhere, a relative, and in some instances an absolute, 
preponderance in the infected aqueous humour, of the 
amboceptor produced in response to the ocular infection. 
Further investigations are essential before this knowledge 
can be practically utilised. 

3. Eesearches on the formation of an amboceptor in 
chronic inflammations are necessary before we can argue 
that these conditions, indicated in acute uveitis, are in 
any way similar to those existing in chronic uveitis. 

4. The " fixation complement " method as a practical 
aid to diagnosis in general deserves far greater attention 
in this country than it receives at present. The vari- 
ability of the presence of amboceptor is one of the chief 
drawbacks to its more universal application. Further re- 
searches will undoubtedly throw much light upon this 
problem. 

Finally, I turn to perform a duty which is at the same 
time a great pleasure — namely, to express my thanks to 
Prof. 0' Sullivan and Dr. Wigham, who have both kindly 
given me every facility for carrying on my work in the 
Laboratory of the Pathology School, Trinity College, and 
who have on many occasions, together with Dr. Spears 
and Mr. White, helped me with useful suggestions. 

I also desire to thank the staff of the Royal London 
Ophthalmic Hospital for their kindness in allowing me the 
use of their valuable library ; and the staff of the Lister 
Institute, London, for their various courtesies. 

In conclusion, I feel it to be my especial privilege as first 
holder of the Montgomery Lectureship, to express my 
gratitude to its founder, the late Mr. Montgomery, Assis- 
tant Ophthalmic and Aural Surgeon for many years in the 
Royal Victoria Eye and Ear Hospital, Dublin. I know 
well that this feeling of gratitude is shared by my audience, 
many of whom knew him personally, and some few of 
whom worked beside him. I know, also, that it must be 
shared by all members of our profession anxious for the 
advance of medical knowledge. 



170 Diagnosis in Uveitis. 

Mr. Montgomery was a man with many and varied 
scientific interests. In ophthalmology he excelled chiefly 
in its optical and physical branches. Of his personal quali- 
ties I feel it unnecessary to speak, for the fact that at his 
death he founded this generous Research Scholarship will 
tell the scientific world far more eloquently than I or any 
of my successors could hope to do, of the zeal and 
enthusiasm of his life-work. 



REFERENCES. 

(1) Aikwriglit. Journal of Hygiene. 1911. 

(2) Axeufeld. The Ophthalmic Review. 1909. " Serum Therapy 

in Ophthalmology." 

(3) Besredka. Zeitschrift f. Immun. u. exper. Thcrapie. 1914. 

(4) Bierbaum and Berdel. Ibid. 

(5a) Browning. British Medical Journal. 1912. 
(5b) ,, Ibid. 1915. 

(6) Brownlie. The Ophthalmoscope. Oct., 1915. 

(7) Bryan. British Medical Journal. 1912. 

(8) Calderaro. The Ophthalmic Review. 1915 

(9) Coats. British Medical Journal. Oct., 1912. 

(10) Dcano. Pioc. of the Royal Soc. of Med. 1910-11. 

(11) Dudgeon. Journal of Hygiene. 1914. 

(12a) ELschnig. Archiv. f. Ophthalmologie. 1911. 
(12b) ,, Zeitschrift f. Immun. u. exper. Therapie. 1914, 

(ly) Ferrien and Dantreille. Int. Congress of Medicine. London. 
1913. 

(14) Frankc. Beriehte liber Held. Ophth. (lesellschaft. 1912 

(15) Eraser. Zeitschrift f. Immun. u. exper. Therapie. 1914. 

(16) Frcnkel and Nicholas. The Ophthalmoscope. Dec, 1915. 

(17) Fuchs. von Graefe's Archiv. f. Ophthalmologie. April, 1913 

(18) (^cbb. Beriehte iiber Held. Ophth. Gosellschaft, 1913. 

(19) Hustings. Journal of Experimental INIedicinc. 1913. 
(20j Hektoen. The Review of Bacteriology. Pt. IV. 1915. 

(21) von Hippel. Beriehte iiber Held. Ophth. Gesellschaft. 1913. 

(22) Kolmer. " Infection, Immunity and Specific Therapy." 

(23) Kritf^chewsky. Zeitschrift f. Ininuin. u. exper. Therapie, 

1914. 

(24) Lel)pr. Bericlite iiber Heid. Oplitli. ( Icselisciiaft. 1907. 

(25) Miyafehita. Klin. f. AugenheilkuiHle. Heilagelieft 48. 

(26) Morax and Loiseau. Annales de I'lnstilut Pastiur. 1911. 



By Dr. PjUPHAN Maxwell. 171 

(27) Onnond. British Medical Journal. Oct., 1912. 
(26) Parsons. " The Pathology of the Eye." 

(29) Plotz, Olitsky and Baehr. Journal of Infi'ctious Diseases. 

1915. 

(30) Prinzing. Zeitschrift f. Imniun. u. expor. ThL'i-ai)ie. 1913. 

(31) Bados. Hid. 1913. 

(32) Rosenthal. Ibid. 1912. 

(33) Salus. Archivs. f. Ophthalmologie. 1910. 
(34a) Schieck. Zeitschrift f. Chemotherapie. 1912. 

(34b) ,, Berichte u. Held. Ophth. Gesellschaft. 1907. 

(35) de Schweinitz. International Congress of Medicine. London. 

1913. 

(36) von Szily. Ibid, 



PORRO S OPERATION. 

Dr. W. Crawshaw {New Zealand Medical Journal, Vol. XV., 
No. 65) reports the following interesting case : — Mrs. L., aged 
thirty years, mother of two children: "A curious feature 
about her confinements was that the uterine contractions 
seem to have caused no pain." Patient was seen on July 23, 
1915. Foetal movements, which had been strong and natural, 
were not felt since June 28. The uterus was found to be 
somewhat more globular than usual ; the fundus reached to 
the level of the ensiform cartilage. The cervix was found 
just behind the pubic bone ; the external os was wide open, 
easily admitting two fingers ; but the internal os was com- 
pletely closed. Behind the cervix the pelvis was occupied by 
a large hard mass the size of a foetal head. " Owing to the 
hardness of the uterus nothing could be felt of any foetal x)arts. 
The patient being anaesthetised, the uterus was exposed and 
excised, and the child, which was sonaewhat above average 
size, was extracted. It was considerably macerated, and lay 
with the head down in the palvis — this being the mass which 
was felt behind the cervix. After the extraction of the child 
the uterine wall remained absolutely flaccid, hypodermics of 
pituitrin producing no effect. As no satisfactory contraction 
of the uterine muscle occurred it was decided to do a Porro's 
operation. The patient made a good and uneventful 
recovery. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Aids to Bacteriology. By C. G. Moor, M.A. (Cantab.), 
F.I.C., Captain 1st London Sanitary Company, Public 
Analyst for the County of Dorset and the Boroughs of 
Poole and Penzance; and William Partridge, F.I.C, 
• Joint Public Analyst for the County of Dorset. Third 
Edition. Loudon : Bailliere, Tindall & Cox. Students' 
Aids Series. 1916. Fscp. 8vo. Pp. viii + 278. 

When reviewing the second edition of this volume of the 
Students' Aids Series in July, 1911 (Vol. 132, page 48), 
we stated that the impression left upon our mind was that 
the book was much more than a mere aide-memoire — that 
it was, in fact, a very full text-book on the subject with 
which it deals, and — we added — " a very reliable guide 
to the practical technique of bacteriological investiga- 
tion . ' ' 

This favourable opinion applies with added force to the 
third edition, published in May of the present year. As 
was to be expected, the Great War has exercised a per- 
ceptible influence on the present issue. We quote the 
autliors' own words from their Preface : — " A war on 
highly-cultivated soil, with troops occupying the same 
ground for lengthy periods, has very forcibly obtruded 
the pathogenic abilities of many ffccal bacteria. Tetanus, 
typhoid, para-typhoid, and dysentery bacilli, the bacillus 
of malignant oedema, and the faecal pyogenic strepto- 
cocci, have all been in evidence. Bacillus Weleliii, under 
one or other of its many names, has also claimed much 
attention in connection with gaseous gangrene. In the 
case of these organisms, however, new developments have 
been chiefly in the directions of pathology and treatment 
rather than in l)acteriology. 



Moor and Partridge — Aids to Bactcrioloriij. 173 

"We have considerably extended our article on, and 
devoted an appendix to, the meningococcus — an organism 
whose life outside the human body remains a matter for 
conjecture. We have collected in one chapter a summary 
of the little that is known about the filterable viruses, and 
have also dealt with anaphylaxis and the preparation of 
vaccines." 

These paragraphs will show the lines of advance in the 
present edition of a book which has come to be regarded 
as a standard work on Bacteriology. 

There is little to criticise adversely in this tidy volume. 
In the account of the meningococcus (page 138), it is a 
pity that the authors adopt the term " Epidemic cerebro- 
spinal meningitis ' ' instead of the more accurate 
synonym "Epidemic cerebro-spinal fever." The former 
appellation suggests that the p}T:exia is due to an inflam- 
mation of the meninges rather than to a reaction against 
the toxfemia — one of the defensive forces of the body. 
The synonym ' ' spotted fever ' ' also should find no place 
in a scientific work on bacteriology — the phrase is am- 
biguous in the first place, for it applies much more closely 
to typhus fever. It is altogether misleading also, for we 
venture to assert that the majority of cases of cerebro- 
spinal fever, or meningococcal fever, show no skin mani- 
festations whatever. 

In our review of the second edition we drew attention 
to some slips in connection with technical terms. Perhaps 
it was unreasonable on our part to hope that the authors 
would read our criticism and adopt our corrections. x\t 
all events, they have not done so, and the pages of the 
book are still disfigured by such errors as " B. dipJitherice 
columharium" (for " columharum") at page 121 and in 
the Index, " B. tohacci " (for " tahaci ") at page 191 and 
in the Index, and " S. furfuri " (for " fur fur is ") at page 
191 and in the Index. " Eczema epizootica " (for " epi- 
zooticum") still appears (page 199). In the Index also 
the word ' ' Bacillus ' ' apparently does duty for ' ' Bac- 
terium " as well, with the result that a small number of 



174 Reviews and BihJioqraphicn] Notices. 

adjectives with a neuter ending appear under the former 
heading. This mistake crops up here and there in the 
text also — see pages 165, 188, 206. " Tholoeideum " 
should be spelled " tholoideum " (page 206). It is 
Gessner's name for a bacterium — " an intestinal organism 
invariably found in sewage. It produces a septicaemia in 
mice and guinea-pigs, and gives yellowish growths on 
potato and gelatin streaks " (pages 206, 207). 



Nerve Injuries and their Treatment. By Pdeves 
Stewart, M.A., M.D. (Edin.), F.E.C.P. (Temporary 
Colonel, A. M.S.); and Arthur Evans, M.S., M.D. 
(Lond.), F.R.C.S. (Captain, E.A.M.C., T.). London : 
Henry Frowde and Hodder & Stoughton. 1916. Demy 
8vo. Pp. xii + 208 Oxford Medical Publications. 

One can speak of this book only in the most appreciating 
way. Both in matter and manner it is admirable, and 
admirably adapted, especially, for the pressing needs of 
the moment. 

The subject is treated very fully and very fairly. Finer 
points which at present have attained to little more than 
academic interest are not dwelt upon, but all well-recog- 
nised observations are set forth clearly and precisely, so 
that there can be no mistake. The book suits the 
beginner from the clear description given of methods of 
examination — as far as a book can teach this last refine- 
ment of clinical artistry — and it helps him and the more 
experienced in very many other ways. Not the least of 
these latter lies in the excellence of the illustrations, the 
l)hotographs, the diagrams, and the shaded charts, of 
which there are nearly one hundred. 

The chapter on prognosis seems to us to be one of the 
most useful summaries of the whole series, for the book 
is a series of summaries, and it leaves us with a spirit of 
hopefulness (the essence of a physician), not to say 
optimism, about the future of neuroplasty, which we trust 
will survive to sustain us under many disap[)ointments ! 



Graves — Gipurcolorin. 175 

The chapter on surgical operations emphasises four 
points which cannot be too often insisted on — cleanliness, 
gentleness, exactness and perseverance in after-treatment. 

Finally, we must express appreciation of the general 
get-up of the book, its large print, handy size, and good 
index. 



Gyncecology . By William P. Graves, A.B., M.D., 
F.R.C.S. ; Professor of Gynaecology at Harvard 
Medical School, &c. With 303 half-tone and pen 
drawings by the Author, and 122 microscopic draw- 
ings by Margaret Concree and Ruth Huestis ; with 
66 of the illustrations in colours. Philadelphia and 
London : W. B. Saunders Company. 1916. 8vo. 
Pp. 770. 

It is a very difficult matter to give Professor Graves's 
" Gynof^cology " a definite place. He suggests that Part 
I., which deals with the physiology of the pelvic organs 
and with the relationship of gynaecology to the general 
organism will be of value to the advanced special student 
and to the general practitioner who includes gyna?- 
cological clientele. We are wondering greatly w^hat 
definition Graves would give of the advanced special 
student. It is our experience that the ordinary student 
wants a book that will teach him clearly his subject ; he 
has no time for special reading. When he is qualified 
and has decided what course he will pursue, then he may 
read such a w^ork as this. The part which deals with the 
relationship of gynaecology to the general organism is 
extraordinarily interesting reading. The relationship of 
gynsecology to the organs of internal secretion and the re- 
lationship to every other part of the body are clearly 
enunciated. The connection of gynaecology with the ner- 
vous system is well known. Opinions still differ as to the 
best treatment to adopt for a woman who is in a " ner- 
vous condition " and has definite gynaecological disease. 
The cure of a displacement often cures such nervous 



176 Revicics and Bihliographicol Noticeft. 

troubles; sometimes it does not effect a cure. Each case 
must be taken on its own merits ; certainly nothing dog- 
matic can be said on the subject. The author's opinions 
on this important point are worthy of perusal. 

Part II. deals with essential gyna?cological diseases, 
and is well illustrated by drawings from microscopical 
sections. There are 122 of these, and they should prove 
useful to the student. The treatment of these diseases 
is recounted, but the technique of operation is reserved 
for Part III. In a review of another gynaecological text- 
book recently we questioned the wisdom of this proce- 
dure, and we reiterate that we consider it more desirable 
to describe treatment at the same time as diagnosis. 

In Part III. the operations are excellently demon- 
strated, and are accompanied by the type of illustration 
which we expect to find in first-rate American text-books. 
If Dr. Graves's skill in operating is as great as his skill in 
illustrating he is, indeed, lucky. There are few writers 
who are so fortunate as to be able to illustrate so beauti- 
fully their own text-books. These illustrations are done 
after the technique of Brodel, to whom the author 
acknowledges his indebtedness. Every modern opera- 
tion is described, and the reader is not wearied with a 
perusal of ancient operations which have long since been 
buried in a well-deserved grave. 

The work has been published by Saunders Company 
in their well-known excellent manner. We can recom- 
mend it highly as a reference work to the specialist and 
to the general practitioner. 

B. S. 

The Mentally Defective Child. By Meredith Young, 
M.D., D.P.H., D.S.Sc. London :" H. K. Lewis & Co., 
Ltd. 1910. Cr. 8vo. Pp. xi + 140. 

In this work Dr. Meredith Young treats of the " question 
of mental deficiency, particularly as it affects school chil- 
dren," from the point of view of school teachers and 



I 



Laboratory Manual in General Microbiology. 177 

others interested in the welfare and training of juvenile 
defectives. 

The importance of making an accurate and careful ex- 
amination of the young patient, at the same time gaining 
his confidence, receives special consideration, and the 
various types of mental deficiency together with associated 
conditions are dealt with in a concise fashion. One 
chapter is devoted to the moral imbecile, and in the 
succeeding chapter the Binet-Simon tests are explained, 
the author showing that he by no means accepts these 
tests as proof positive or negative of mental deficiency. 

Dr. Young considers that these children should begin 
their education at an earlier age than seven years, and he 
lays much emphasis on the necessity for the adoption of 
manual training as soon as an elementary knowledge of 
general subjects has been acquired ; he advocates that 
" the last two years of each child's education in a special 
school or class should be almost entirely manual." 

The author dwells on the imperfectly recognised fact 
that good-looking and well-developed children frequently 
constitute the worst cases. The requirements for special 
schools are considered at length, and an extensive 
appendix deals with the legislation on the subject of his 
work. The book is provided with suitable illustrations 
and schemata. 



Laboratory Manual in General Microbiology. Pre- 
pared by the Laboratory of Bacteriology, Hygiene and 
Pathology, Michigan Agricultural College. First 
Edition. First Thousand. New York : John Wiley & 
Sons, Inc. London : Chapman & Hall, Ltd. 1916. 
8vo. Pp. xvi + 418. 

The subject-matter given under Part I. of this manual is 
primarily for the purpose of giving a working knowledge 
for use in the study of micro-organisms. Part II. consists 
of exercises demonstrating the various physiological 

N 



178 Reviews and Bibliogrnphieal Notices. 

activities of micro-organisms. Part III. deals with 
applied microbiology. 

The book gives us an idea of the scope and character of 
the laboratory instruction given in bacteriology at the 
Michigan Agricultural College. It is divided into a 
number of exercises, and may be said to begin at the 
beginning, for the first exercises deal with the cleaning of 
glassware, the preparation of glassware for sterilisation 
and the making of nutrient media. From 'these com- 
paratively simple beginnings, it works its way through 
the microbiology of air, water, sewage, soil, and the role 
of bacteria in the dairy, ultimately finishing up with 
a number of exercises on animal diseases and immunity 
which include animal inoculation, a study of the anthrax 
bacillus, the preparation of tuberculin, the preparation of 
" blackleg " vaccine, the preparation of tetanus toxin and 
antitoxin and a demonstration of the agglutination test : 
a study of filterable viruses, the preparation of bacterial 
vaccines, the demonstration of opsonins and precipitins, 
the production of a hsemolytic serum and the demonstra- 
tion of the complement-fixation test. From this it will be 
seen that the course of instruction covered is very exten- 
sive, surpassing, as far as we are aware, the limits of any 
course in this subject given at any institution in the United 
Kingdom. 

To the medical bacteriologist this manual will be of 
great use on account of the information which it 
imparts about portions of the subject with which he 
is often unfamiliar. Thus, for example, the action of 
enzymes is very fully dealt with. There are exercises 
showing the action of proteolytic enzymes upon gelatine 
and casein ; the action of enzymes utx)n starch : the 
action of reducing enzymes; the action of enzyme 
catalase : of the oxidising enzymes of vinegar bacteria : 
and there is an exercise to demonstrate the necessity for 
an activatcjr for the enzymic action of rennet. There 
are also exercises to demonstrate the cellulose-decompos- 
ing power of an anaerobic organisms found in the soil : to 



Laboratory Manual ni General Microbiology. 179 

illustrate nitrification and de-nitrification in solution : to 
illustrate the non-symbiotic fixation of nitrogen by soil 
organisms and isolation of the Azotobacter through its 
mineral food requirements. We also find a study of the 
symbiotic nitrogen-fixing organism of legumes — Pseudo- 
monas radicicola. Of special interest to the medical 
analyst are such exercises as the following : — 

The demonstration of the phenol coefficient of some 
common disinfectants : of the action of formaldehyde 
upon the microflora of milk : of the efi&ciency of chloride 
of lime as an agent in the piu'ification of drinking-water, 
and the mode of investigating the amount and kind of 
dirt in milk and its relation to its microbial content. 

When we consider that the most explicit and unmistak- 
able directions are given for the carrying out of such 
widely different procedures — directions which only need 
to be accurately followed in order to get the information 
required, it will be seen that this book constitutes a valu- 
able addition to the laboratory book-shelf. It is suffi- 
ciently, though not profusely, illustrated, the plates con- 
sisting for the most part of photographic reproductions, 
not of the natural objects, but of gelatine models on a 
large scale. There is a diagrammatic plate on Ehrlich's 
side-chain theory, but it requires pretty careful study, 
and does not seem to constitute an improvement on well- 
known diagrams already in use. 

Many of the directions given seem to be of the nature 
of "councils of perfection." Take, for instance, the 
exercise on the bacteriological analysis of water from a 
source not suspected of sewage contamination. The 
apparatus required comprises, amongst other things, 
twelve tubes of litmus lactose agar, twelve salt-free gela- 
tine tubes, two litmus lactose-bile-fermentation-tubes, six 
agar slants, six tubes of Dunham's solution, six tubes of 
sterile broth, six tubes of nitrate peptone solution, six 
dextrose fermentation tubes, six tubes of litmus milk, and 
twelve sterile Petri dishes ! 

Bacteriologv would, indeed, be a fonnidable proce- 



180 Reviews and Bihliographical Notices. 

dure were it not possible to arrive at a fairly well-grounded 
conclusion without using up such large quantities and so 
many different kinds of nutrient media. The methods 
practised on the whole are excellent, but one cannot help 
noticing to how small an extent British work has in- 
influenced the writers. It is true that Wright's plan of 
using the air-bubble-index is adopted in exercise 11 on 
the Demonstration of Opsonins, but it is suggested 
in connection with the Agglutination Test, where, per- 
haps, it is most useful, as the quantities of serum obtain- 
able in ordinary diagnostic work on the human subject 
are rarely sufficient to allow of a test being carried out by 
any other plan. 

The text is not without its flaws. For instance, on 
page 139, Method, paragraph 3, we are not told to what 
temperature the milk tubes should be heated. On page 
187, at top, .5 per cent, should be 5 per cent. — without 
the decimal point. Sometimes unnecessary directions are 
given, as on page 239, where dilutions of 1 in 100 and 
1 in 10,000 are recommended to be made from a presum- 
ably sterile Berkefeld filtrate. 

These minor errors do not detract from the value of the 
book, which is undoubtedly very great. 

We hope we have said enough to bespeak for it the 
welcome which it undoubtedly deserves from all classes of 
workers in Bacteriology and Microbiology. It will, we 
believe, be chiefly of use to Agriculturists and Veteri- 
narians, but to the Medical Bacteriologist it can also be 

highly recommended. 

E. J. McW. 

The Child Welfare Annual. Edited by T. N. Kelynack, 
M.D. Vol. I. London : John Bale, Sons & Danielsson, 
Ltd. No date on Title-page [June 1, 1916, in Preface]. 
Pp. Ixi -f- 346. 

We have noted before that Dr. Kelynack is a master of 
compilation, and in his most recent production — " The 
Child Welfare Annual "—he has again proved his right 



ScHAFER — The Essentials of Histology. 181 

to the title. The book is to be used as a directory to all 
organisations connected with the welfare of children. It 
is a very good book of reference for all who are connected 
with work among children, and might with advantage be 
found on the desk of every secretary of a philanthropic 
society. As well as forming a good directory its interest 
is increased by the insertion of original articles on the 
subject of child welfare by well-known authorities. 

A great drawback from the point of view of workers in 
this country is that hardly any reference is made to work 
in this country. If England only were referred to in the 
book confusion would be avoided; but two references are 
made to organisations in Dublin, which, as only two are 
mentioned, gives a very one-sided view of the work in 
this City. 

The work is published by Messrs. John Bale, Sons & 
Danielsson, Ltd., of London, is illustrated, and is sold at 
seven shillings and sixpence. 



The Essentials of Histology, Deseriptive and Practical, 
for the Use of Students. By Sir Edward A. Schafer, 
M.D., Sc.D., LL.D., F.K.S. ; Professor of Physiology 
in the University of Edinburgh ; formerly Jodrell Pro- 
fessor of Physiology in University College, London. 
Tenth Edition. London : Longmans, Green & Co. 
1916. Demy 8vo. Pp. xi + 563. 

This well-known text-book has again proved that it fills 
a place in medical education by the fact that another 
edition has been called for within the short interval of 
two years. The present volume, the tenth edition, is the 
first which has appeared since its author has had, the 
distinction of knighthood conferred upon him by His 
Majesty, and never has that honour been more worthily 
bestowed. 

The work is beyond criticism as. an exposition of the 
subject. In this edition some few alterations have been 
made. Notwithstanding the insertion of some new 



18-2 Reviews and BihUographical Notices. 

matter and many new illustrations, the actual number of 
pages is decreased, space being obtained for the additions 
by a very small increase in the size of each page. 

. The principal additions to the text are in the pages de- 
voted to the ductless glands, which have been brought 
up-to-date. This subject has been dealt with in a chapter 
of very great importance considering the various ques- 
tions of function and treatment of disease associated with 
the secretions of these glands. 

A large number of new illustrations has been added. 
These are very largely reproductions of photographs of 
the tissues, a few of which replace diagrams previously 
used. 

As in former editions, a very large proportion of the 
plates are in colour in close imitation of the appearance 
of the staining methods commonly used in the prepara- 
tion of sections. In some of these the brown tint in imita- 
tion of silver nitrate staining has been made much more 
like the colour of the stain than was the case in former 
editions. 

It is hardly necessary to specially recommend this 
work which has become almost a necessity for any one 
working at the subject. But there may be some who are 
studying clinical subjects from the point of view of the 
tissue changes. These medical practitioners or students 
will find the present edition a suitable one in which to 
obtain a modern account of the various structures in the 
body in health. 

Urine Examinatiuu }iiade Easy : A Plan of Examination 
with the Common Tests fully described. By Thomas 
Carruthers, M.A., M.B., Ch.B. Third Edition. 
London : J. & A. Churchill. 191G. Pp. 45. 

The second edition of this booklet was published in 1911, 
and a notice of it appeared in the number of this Journal 
for June of that year (Vol. 131, page 442). It consists 
of notes prepared by the author in connection with the 



IvETTLE — The Patholoyy of Tumours. 183 

teaching of urine examination to the Nurses in the City 
of Glasgow Fever Hospital, Ruchill, Glasgow. Dr. 
Carruthers modestly suggests that "though intended 
primarily for the use of Nurses, it may possibly be of 
service to others." We agree with him. At the same 
time, we think that a little more detailed information 
might have been given here and there. For example, in 
describing Test IV., for sugar by Fehling's solution, the 
author might very well have contrasted the beautiful dark 
blue clear solution which constitutes the test with the 
"brick-red or yellowish precipitate," which indicates the 
reduction by glucose of a cupric to a cuprous salt. The 
composition of the Fehling's solutions " No. 1 " and 
" No. 2 " is not given. This is certainly an omission if 
the book is intended to be of service ' ' to others ' ' than 
nurses. The author is rather extravagant in using the 
Fehling's solution. He writes (page 31) : — " Put an inch 
deep of ' Solution No. 1 ' into a test-tube. Make it up 
another inch with ' Solution No. 2 ' " — that is not " war- 
time economy." 

The Tables in the book are admirable. The insertion 
of blank leaves for notes of further tests than those given 
in the text was a happy inspiration. 

Type and paper leave nothing to be desired, but 
" Urine Examination made Easy" deserves more than 
the frail shell of a paper cover in which it is enshrined. 
How long will such a setting stand the wear and tear of 
daily use in hospital or private practice ? The price of the 
booklet is one shilling net. krx additional threepence 
would provide a more substantial cover. 



The Pathology of Tumours. By E. H. Kettle, M.D., 
B.S. London. London: H. K. Lewis & Co., Ltd. 
1916. Demy 8vo. Pp. viii -1- 224. 

This is quite a small book containing nothing very ])ro- 
found or original, but still one of the best we have met 



184 Ueviews and Bihtiographical Notices. 

with recently. Its purpose, as the author states in the 
preface, is to present as briefly as possible the chief 
points bearing on the general and special pathology of 
neoplasms. 

The work is divided into three parts — General Biology, 
General Pathology, and Special Pathology — and from 
start to finish is full of interest. 

While the newer classifications and theories are briefly 
and clearly stated, the teaching follows the generally 
accepted lines as regards classification and nomencla- 
ture — a point of some importance to the average reader. 

The subject-matter of Part I. is of such absorbing in- 
terest in itself that with his command of English the 
author has no difficulty in fixing one's attention from 
the first page. In Parts II. and III., where the subject- 
matter is more commonplace, we find we are in for no 
dull excursus on a well-worn theme, but are present at 
a demonstration of his own specimens by a master. The 
lecture is illuminated by graphic descriptions of out-of 
the-way incidents in his own experience, and by copious 
first-rate illustrations. 

Dr. Kettle's treatment of endotheliomata is particularly 
good — a subject studiously neglected in many much more 
pretentious books, and he has some arresting observations 
on the accidental implantation of cancer which should be 
useful to the operating surgeon. 

Acute injury as a forerunner of sarcoma does not seem 
to have been noticed by him in a general way, although 
he does record three very curious instances of melanoma 
following a wound by a rusty nail. 

It is refreshing to read a book written in real English, 
with a "preface" not a "foreword," and about 
tumours. The index is complete and accurate. There 
are no misprints, and the type is clear. His careful 
drawings from good sections make much better illustra- 
tions for a book of this sort than micro-photographs. 



Faulkner — Works on the Tonsil. 185 

Handbook for Wives and MotJiers in India. By Mildred 
Staley, M.B., L.M., late Physician to Lady Aitcheson 
Hospital for Women in Lahore. Second Edition. 
Calcutta and Simla : Thacker, Spink & Co. 1916. 
Cr. 8vo. Pp. X + 344. 

We are glad to see a second edition of Dr. Mildred 
Staley 's well-known work. The book has appeared in 
very much the same form as the first edition, but has 
additional remarks on the subject of breast-feeding, 
citrated whole milk, &c. The book contains many good 
hints as to the management of health under the some- 
what trying conditions of Indian life, but it might also be 
read with profit by wives and mothers in this country. 



WORKS ON THE TONSIL. 

The Tonsil and its Uses : Vocal, Mechanic and Physio- 
logic. By EiCHARD B. Faulkner, M.D. (Columbia 
University). Pittsburg, Pa. : The Blanchard Company. 
1916. Pp. -29. 

Tonsils and Adenoids : I'reatment and Cure. By 

Richard B. Faulkner, M.D. (Columbia University). 

Pittsburg, Pa, : The Blanchard Company, 1915. Pp. 
30. 

The two pamphlets before us are intended mainly for 
American readers, and from their contents, one would also 
gather that the lay reader was catered for rather than the 
medical profession. To this we cannot have the smallest 
objection, provided that the writer, in trying to set aside 
one abuse, contents himself with a proper statement of his 
case, and does not allow the pendulum to swing too far to 
the other side. 

There are a good many absolute mis-statements in the 
papers. These are probably capable of explanation, but 
the ordinary reader would certainly take the wrong mean- 



186 Reviews and Bihliographical 'Notices. 

ing out of the expressions used. We are well aware that 
quite unnecessary operations have been performed on 
adenoids and tonsils, especially the latter, in America. We 
have been bombarded with papers on enucleation of the 
tonsil, but one can hardly believe that in this country, at 
any rate, it would be necessary to make the following state- 
ment to a medical audience : — " In all cases of primary 
inflammation of the tonsil, the operation for removal can- 
not be too strongly condemned." There is no question 
that the author is correct in laying great stress on the fact 
that the tonsil has its uses, and should not be removed; 
that mere enlargement without obvious disease is no reason 
for removal ; but surely he might have gone on to add that 
reasonable operation on badly diseased tonsils will restore 
many a patient to health. He quotes several cases where 
singers and other voice-users have lost their voices through 
the removal of tonsils. This obviously applies to the com- 
plete enucleation, and probably largely depends on the fact 
that adhesions took place between the various muscles sur- 
rounding the tonsil. He makes many quotations from 
various well-known throat specialists and teachers of sing- 
ing, many of which tend to prove various points quite at 
variance with the cause in favour of which they are brought 
forward. For instance, how does the following remark 
helj) us to decide w^hether a diseased tonsil should 
be removed or not? — " It seems evident that the hyper- 
trophied and diseased tonsil could not come to the defence 
of the system, while the normal tonsil could not be a source 
of infection." 

We have not had the oj)portunity of reading the author's 
larger work on the Tonsils and the Voice, to which he 
constantly refers in the pamj)hlet before us. In dealing 
with the question of infection to the tonsils, he says that 
it always comes from the nose, and enlarges on the fact 
tliat the ordinary person living in a civilised country 
breathes in an enormous amount of infectious material 
during the day, and he then suggests that an occasional 
washing out would entirely prevent this. So far as we are 



CuLLEN — Dis('asc>i of the Uiiibilicus. 187 

concerned, we should much prefer to allow the natural 
method of protection, which works extremely well, and 
is going on through the whole twenty-four hours' round, 
to have full play and be unhindered, than to trust to an 
occasional wash. If the author had been an operator on 
the nose, he would realise how wonderfully perfect the 
antisei^tic precautions of Nature in the nose are, provided 
they are not interfered with by using various antiseptics 
which can only neutralise or hinder the ordinary defensive 
forces in their work. 



Euihrijologij, Aiiatomij, and Diseases of tlie Ihnbilieus, 
together with Diseases of the Urachus. By Thomas 
Stephen Cullen, Associate Professor of Gynsecology 
in the Johns Hopkins University ; Assistant Visiting 
Gynaecologist to the Johns Hopkins University. Illus- 
trated by Max Kiodel. Philadelphia and London : W. 
B. Saunders Company. 1916. 

This large square 8vo volume of 800 pages and "276 illus- 
trations, which are beautifully drawn, and seven of which 
are plates, is a valuable addition to medical literature. 
It may fairly be said that the book " Umbilicus and its 
diseases " is a compilation made possible by the use of 
the index-catalogue and the " Index Medicus." It is so; 
and throughout the volume our admiration is excited by 
the diligence and care of the author in collecting, classi- 
fying, arranging and making available for the medical 
profession the great mass of information of which the 
above-named publications are the key. This labour of 
itself should be thankfully recognised ; but Dr. CuUen does 
more than this, he enriches the compilation with an 
account of his own experience, his interpretation of the 
facts, and his theories. The genesis of the book is due 
to the self questioning of the author over a case of adeno- 
carcinoma of the umbilicus, which he excised in 1904. 
Self questioning of the intelligent has ever been fruitful 



188 Reviews and BihliograjihicaJ Notices. 

with benefits. It led Pare to tie wounded arteries ; 
Jenner to use vaccine lymph ; Louis and the younger 
Jenner to differentiate typhoid from typhus fever ; Waller 
to recognise the initial stage of inflammation ; Higgins to 
recognise the valency of chemical compounds ; Priestley to 
discover oxygen ions ; and C. W. Long to discover surgical 
anaesthesia. The adeno-carcinoma of the umbilicus at once 
appeared to the author as a problem worthy of study ; and 
it was equally plain to him that an explanation of the 
phenomenon was to be found in the evolution and de- 
velopment of the embryo. The who*le available literature 
on the subject of the umbilicus and its diseases was laid 
under tribute and thanks to the forethought of the United 
States Government. Medical authors have unequalled 
facilities for research in the Surgeon-General's library, 
where every facility is offered to students. 

The author quotes Montgomery, of Dublin, at second 
hand, on discoloration of the navel; and Dr. James 
Isdell's paper dealing with the risk of including a portion 
of intestine or other contents of the abdomen attendant on 
ligature of the umbilical cord. We are not, however, sur- 
prised — Murphy's, Isdell's and Waller's works are as 
little known in Dublin as in Baltimore. 

In the thirty-nine chapters which make up the book 
the author passes from the embryology of the umbilical 
region, which is illustrated by many coloured j^lates, to 
the anatomy of the region, and in Chapter III. he enters 
on the study of the diseases by an account of septic infec- 
tions. A chapter on luemorrhages follows. Eemnants 
of the om])halomesenteric duct are the subject of Chapter 
VI., and this is followed by a series of chapters on polypi, 
cysts, fistula, and an account of patent omphalomesenteric 
ducts. Five chapters are devoted to the study of umbilical 
tumours and umbilical hernia. The question of hernia is 
rather briefly dealt with, as the author considers it is 
sufficiently discussed in text-books ; but if the letterpress 
on the subject is scant the illustrations are many, exqui- 
sitely drawn, and most helpful. 



Patterson and Traquaih — Visual Standards. 189 

Chapter XXVIII. and the remaining eleven chapters 
deal with congenital and acquired diseases of the urachus. 
We know no monogram on the subject so full, so inform- 
ative, so exhaustive, or so valuable. The book, how^ever, 
has a great fault. It is printed on thick, highly-glazed 
paper, which makes it too weighty to hold in reading, and 
painful to the eyes in reading. We sincerely hope to see 
the next edition in unglazed paper, and in two easily 
handled volumes. 



Tlie Visual Standards Used in the Medical Examination of 
Recruits in the British Army and Continental Armies. 
By J. V. Patterson, F.K.C.S. Edin., Ophthalmic 
Surgeon, Royal Infirmary, Edinburgh; and H. M. 
Traquair, F.R.C.S. Edin., Assistant Ophthalmic Sur- 
geon, Royal Infirmary, Edinburgh. 

This short pamphlet, reprinted from The Lancet, May 6, 
1916, shows that the British Armv, even on a war footing, 
demands a much higher standard of its recruits than any 
of the Continental Armies on their peace footing. Our 
Army requires its recruits to show a minimum of vision 
without any correction by glasses. That minimum is 
6/24 in the right eye and 6/60 in the left, according to this 
pamphlet. This, of necessity, excludes any man who has 
2.5 D. and 3.5 D. of myopia. All the Continental Armies 
allow the recruits correction by glasses and then calculate 
the amount of vision : Germany and Austria allow 6 D. of 
myopia ; France and Italy 7 D. 

Obviously if we want an enormous army (as w^e do) the 
standard of vision must be revised so as to allow^ recruits 
to use glasses. We have reason to believe that the British 
Army Standard has been to some extent revised, but 
perhaps insufficiently, in view of the great demand for 
men. 



PART III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scientific Intelligence. 



THE PROBLEM OF TUBERCULAR SOLDIERS DIS- 
CHARGED FROM THE ARMY .a 

By John Lumsden, INI.D., Deputy Commissioner of the St. 
John Ambulance Brigade, No. 12 (Irish) District, and 
Director-in-Chief for Ireland, Joint St. John and Red 
Cross V. A. D. 

In dealing with pulmonary tuberculosis there are three classes 
to be considered : — 

Class 1 . — The incipient, with a fair prospect of cure provided 
selected and open air work can be procured after treatment. 

Class 2. — The fairly advanced, in which sanatorium treat- 
ment offers some prospect of relief and may arrest for a time 
he progress of the disease, but a return to city life will almost 
certainly be followed by a recrudescence and early death. 

Class 3. — The hopelessly incurable arid dying. 

Class 1 (Incipient). — It must be reaUsed that this class is the 
smallest. The disease being so insidious is rarely diagnosticated 
in its early stage, and then only by experts when the 
presence of tubercle bacilli in the sputum is frequently not 
demonstrable. In such cases sanatorium treatment offers a 
good prospect, but a permanent cure can be effected in most 
instances only if the man can live a healthy open-air hfe for 
two or three years after discharge from hospital. A life of 
privation in an unhealthy environment will almost certainly 
lead to relapse. Notwithstanding Mr. Lloyd George's promise 
of a life in a first-class hotel and a cure in three to six months, 

» A Report to the Tuberculosis Sub-committee of the St. John Ambulance 
Brigade and the County Dublin Branch of the British Red Cross Society. 



The Problem of Tubercular Soldierfi. 191 

it has now been realised that this was a myth, and the money 
voted by Parliament was wasted. It never should have been 
spent in this way. 

If sanatorium treatment is to effect any practical result for 
the labouring classes, it must be followed by an after-cure, 
and this could be brought about by the estabUshment of 
colonies or farms where the services of such men might be 
utilised for agricultural work in selected country places. 
This may sound Utopian, but if the problem is to be tackled 
with success some such scheme must be devised. 

Discharged soldiers in this class should be sent to sanatoriums 
and the State should pay for it ; if not bearing the entire 
expense a substantial contribution should be made. If the 
pubUc or philanthropic bodies wish to assist it might be in the 
direction of supplying suitable work for these men A\hen dis- 
charged, or contributing towards the estabUshment of colonies 
on the land. In Co. Dublin this class could be dealt with 
at either Newcastle or Peamount Sanatorium, and I would 
recommend the acquisition of a ward of from 10-20 beds. 
This would cost about £1 5s. a bed per week. 

Class 2. — When the disease is well established there is un- 
doubtedly a difficulty in the present state of legislation. 
Sanatorium treatment offers little or no prospect of permanent 
rehef, and money spent on such cases is wasted. This is the 
class which to-day fiUs most of our sanatoriums and hospitals — 
it is this class which Lloyd George failed to cure, and it is 
probably this class which is responsible for much of the 
infection so largely disseminated. 

In the case of soldiers in this class, I can make no practical 
suggestion except that these cases should be rejDorted to the 
Medical Officer of Health, whose duty it should be to deal 
with them. 

Class 3. — The advanced and dying cases should undoubtedly 
be segregated, and this, to my mind, is the class the State 
can and should deal with first. They should be segregated 
by legal enactment, and should be compelled to go to hospices, 
as they are dangers to the public health, and until this is 
done no real headway can be made in eradicating the disease 
or lessening its terrible mortality. 

In the case of ex-soldiers in this class I would suggest that 



192 TJie Problem of Tuherndar Soldierfi. 

an effort should be made to get them to voluntarily enter 
hospices like Harold's Cross Hospice for the Dying and the 
Protestant Rest for tlie Dying. These cases should also be 
reported to the Sanitary Authority, who should have their 
homes visited, contacts examined, and disinfection carried out. 
Our experience, however, is that it is very difficult to get dying 
consumptives to go to an institution for dying cases, and as 
the hopefulness of consumption (Spes phthisica) is a well- 
known feature, it is usually hard to get these poor people to 
recognise that their cases are beyond human aid, and the 
natural desire to die at home is great. They do not possess 
a sufficient enlightenment to realise, as is so often the case, 
the great risk of infection to their families, living as they do 
in overcrowded rooms. This being so, it is undoubtedly the 
duty of the State to segregate them and remove the risk to 
the healthy. Notification should, of course, be carried out in 
all cases, but as this has been voluntary it has practically 
become a dead letter. The problem of the treatment of con- 
sumptives is as great to-day as ever, notwithstanding all that 
has been attempted, and no doubt when the War is over fresh 
legislation on sounder lines will become necessary. Mean- 
while, the problem as it affects ex-soldiers is one which might 
at once be taken in hand as part of a general scheme for the 
care and treatment of brokendown and incapacitated men 
who have been discharged from the Army. I think this should, 
therefore, be fully discussed with the War Office, and local 
tuberculosis committees should be set up on which I would 
suggest might sit representatives of : — 

1. The Military. 

2. A representative of the Soldiers and Sailors' Help 

Society. 

3. A representative of the Joint St. John and Red 

Cross V. A. D. Committee. 

4. The Medical Officer of Health. 

5. Tuberculosis specialists. 

6 Any others, such as well-known business men or 
practical workers. 
I have no doubt after the War the St. John Ambulance 
Brigade could supply women who would gladly act as district 



The Problem of Tuberculor Soldiers. 193 

visitors to the homes of consumptives, making regular visits, 
reporting to the Committee, and keeping in touch with local 
Samaritan Committees, who might supply comforts and food- 
stuffs. 

When peace comes and Red Cross work qua Red Cross is 
finished, we wish to find work for our large, well-organised, 
and well-discipUned body of women members, many of whom 
will by then have had considerable experience as nurses in 
Red Cross and military hospitals, and in assisting in a practical 
and well-thought-out tuberculosis scheme, might be one of 
the many ways in which their services could be utilised with 
advantage. 

In dealing with the problem of discharged tubercular 
soldiers in Dublin I can only mention tentatively the following 
suggestions which might be tried experimentally and should 
not cost much. The money, no doubt, could be found by the 
Joint Red Cross and St. John and the Soldiers and Sailors' 
Society to supplement any Government grant. 

SUGGESTIONS. 

1. The acquisition of a ward at Peamount or Newcastle 
Sanatorium of, say, from 10-20 beds, at a cost not exceeding 
25s. per week for each occupied bed. 

2. That only those cases having a reasonable prospect of 
cure should be sent to the sanatorium. 

3. That arrangements be made with Harold's Cross Hospice 
for the Dying and the Protestant Rest for the Dying at 
Camden Row for the admission of hopeless cases. 

4. The setting up of a permanent committee on the lines 
indicated, which shall be the responsible body to whom all 
such cases of pulmonary tuberculosis should be referred. 

5. The formation of a small staff of voluntary workers who 
would undertake district visiting on an organised basis. This 
the St. John Ambulance Brigade or Joint Red Cross V, A. D. 
might do. 

6. The estabHshment of agricultural colonies in selected 
places in the country where men discharged from sanatoriums 
could be given employment. No doubt their working capacity 
will be diminished at first, at least one-third, but in suitable 
environment they would soon be able to do a full day's work, 

Q 



194 The Prohinn of Tubercular Soldiers. 

7. The establishment of an institution for incurable soldiers 
near the city would be admirable ; and if the Government 
would contribute I have little doubt the pubhc would hberally 
subscribe to such an undertaking. 

I would further suggest that a round-table conference be 
held with a War Office representative to discuss the whole 
question. When we know what assistance Government will 
offer, a scheme might be evolved which I have little doubt 
would receive sympathetic and practical assistance from the 
pubUc, who owe a debt of gratitude to these poor men as 
much as to those who have been wounded in the country's 
service. 



THE TECHNIC OF APPLYING HEAT IN THE TREATMENT OF 
INOPERABLE UTERINE CARCINOMA. 

This is the title of a valuable article by Dr. Percy {Pacific 
Medical Journal, Vol. LIX., No. 2). He maintains that a low 
degree of heat has an infinitely greater psnetrating power, as 
far as distance is concerned, and that a high degree of heat, 
producing a charcoal core, psrmits of a ver}^ limited dissemina- 
tion of heat. A heat sufficient to form a charcoal core rapidly 
becomes dangero\is to structures contiguous to, but outside of, 
the cancerous area. Tlie curette should never be used before 
the heating iron. Wlien the tissues are thoroughly permeated 
by the heat, the cells are fixed in such a way as to become 
immediately available for sectioning and staining %vithout the 
further use of the usual hardening methods. At the same 
time the heat seals at once the lymphatics and blood vessels, 
preventing the further dissemination of the cancer and mixed 
infection. In addition, the immediate nerve supply is cut off. 
Both ovaries are removed to limit the blood supply, to bring 
on the menopause, and avoid the painful dysmenorrhcea 
which occasionally follows the application of heat. The 
technique of tlie operation is rather elaborate ; being freely 
illustrated, and requiring specially designed instruments, it does 
not admit of being summarised. The principle of the treat- 
ment is, however, intelligible, and can be applied by gynae- 
cologists without any groat difficulty. 



The Great Offensive, Picardy. 195 

THE GREAT OFFENSIVE, PICARDY. 
July, 1916. 

The following graphic description of the recent British ad- 
vance on the German lines was written by an Irish physician 
and surgeon, serving in the Royal Army Medical Corps at 
the Front in France. His letter was addressed to his uncle, 
an eminent Dublin physician. It cannot fail to interest our 
readers, although it contains little mention of the writer's daily 
and increasing work among the sick and wounded of the 
heroic " British Expeditionary Force." 

France, 

July 20th, 1916. 

My Dear E , 

I write in my tent, close to a fair-sized town, which just 
now the Huns shell. I hear the shells come in as I write. 
Behind me are our " heavies," while in front is a con- 
tinual thunder, where our 18 pounders keep going night and 
day. It is stimulating, too much so, for letter- writing, but 
I have not written for so long that I feel I must. 

When last I wrote I told you of slow but certain prepara- 
tion, continual work night and day, never rushed or inexact, 
but just a daily business. Here barbed-wire put up, there 
a sawmill, a waterworks, but through all the traffic passed; 
now a regiment back to rest, again loiTies and new regiments 
coming up. The face of the country changed with each day; 
slowly, certainly, but always on; for every unit, dump, or 
waterworks one passed or saw grow, marked another milestone 
passed and our offensive so much nearer. I do not think a 
day was fixed on which to be ready; we just went on till all 
was ready, and when I last wrote you we waited the word 
and the weather, for the latter is more important than the 
papers would lead you to suppose, and always takes an im- 
portant place in calculations. The country for miles back 
from the firing line was dotted with gun positions — in fields 
of growing wheat, in ditches, hedges, groves, everywhere a 
gun could be found (if you looked for it), for they were well 
concealed, and rarely fired until they were wanted. In front 
were our first-line trenches and supports; behind, our horse 



196 The Great Offensive, Pieardy. 

transport and reserve infantry and artillery, away from shell 
fire, but near enough for use when necessary. A, perfect con- 
fusion if one did not know how it grew and why. Its ration- 
ing was a marvel ; not a man but got his rations, less 
luxuriously perhaps than in quieter times, but all the same, 
full, square meals for all and food to spare, but no waste. 
At last, on June 25th, all was complete, and at 4.30 a.m. 
our bombardment started, not suddenly and with demonstra- 
tion, but slowly, methodically, deliberately, as one would 
punctuate a hastily-written letter. They seemed, when 
listened to, to search and fire, as indeed they did. Our line 
was marked by captive balloons at intervals of about 1,000 
yards each, with its telephone to a gun or guns, while the 
aeroplanes hummed overhead both marked and reported the 
effect of the fire, which steadily grew in intensity until an 
hour before the preliminary assault. Why such a long bom- 
bardment? you might say, but we knew we were up against 
one of the strongest defensive positions on the Western front 
— a perfect maze of tunnels, trenches, and woods and barbed- 
wire, with houses and villages thrown in, and all, particularly 
the wire, had to be destroyed. The latter is not a simple 
fence: it is, roughly, 20 feet wide, a veritable tangle, 3 feet 
high, and row behind row, in front of each trench, through 
every wood and village. To destroy it by shell fire seemed 
impossible. It could, perhaps, be done by raking every foot 
of the ground two, perhaps three, times over, and this they 
did. On most days of the bombardment I got to a point of 
vantage, and watched the effect of our fire. Nothing on the 
surface of the ground was left ; villages disappeared and woods 
became leafless; on one day one would see a group of trees, 
a house, an untouched trench, next day they would have 
disappeared, a mass of tumed-up earth would mark their 
place. The hillside, as I looked closely at it from an artillery 
observation post close up, did not disclose a moving object; 
it was just a sea of plunging shells on that last day before 
the assault. The dug-out, 30 feet deep, and the tunnel was 
a harder nut to crack; hence the repeated gas and smoke 
attacks on successive days; and even then, and with all the 
preparations, I marvel to think of what our infantry did. The 
whole countryside was a maze of galleries undergroimd, with 



The Great Offensive, Picardy. 197 

hidden machine guns. One could guess it, but not realise it. 
Our men knew what was there, but they went on when their 
time came. 

It arrived at 7 o'clock on July 1st. At 6 o'clock 
the most deafening bombardment arose ; the air simply 
quivered ; no wind could make a more awful noise than the 
passing shells made for that last hour, and then at 7 o'clock 
dead silence, or what seemed like it (I was two miles back), 
for ten minutes. After that a low roar: the Huns' machine 
guns and shrapnel were at work. We knew our men were 
up and over the parapet. We back there could only wonder 
how things went, and be busy at ordinary work. We heard 
the Huns' shrapnel and machine guns. Nothing, one would 
think, could live in such a fire; but two hours later we are 
told our men have all the first line trench, are held at one 
spot, but advancing to right and left. What " held " meant 
at such a time in such a fire we realised. We all had friends 
in it. 

At 12 o'clock right and left had advanced further; centre 
still held. At 3 o'clock our guns have broken out again. 
We hear our left has fallen back somewhat. A village and 
wood are a veritable redoubt. The ambulances begin to come 
in ; I go to the nearest hospital to help and to occupy myself 
rather than think. The news is confirmed : our centre and 
left are held. All wire is well cut, but machine-guns are 
in the dug-outs in the wood, and mow our men down when 
they advance. W^e hold positions right and left well ad- 
vanced; this fortress in our centre still stands; hence the 
renewed artillery fire ; and so it was for the night. Next day 
at 3 o'clock the fortress falls; our men have now the whole 
Hun first line, and are attacking the supports. All we in- 
tended for the first two days has been achieved, and won. 
Every one is relieved. " Boot and Saddle " is the order; we 
pack and stand by, ready to move at a moment's notice. 

We do not move till next day, and in the meantime I assist 
at the nearest field ambulance. Only the more slightly 
wounded come there. They are elated ; they have done well, 
and are proud of their regiments and of themselves. 

Next day, July 3rd, I come here, and settle down in a new 
camp, two miles forward. Our line has gone on, and we move 
to correspond. It marks our advance in three days a wonderful 



198 The Great Offensive, Picardij. 

achievement. How wonderful I only realised next day, when 
(in search for the field ambulance in which to help) I find 
myself in yesterday's battlefield. The dead lie where they 
fell, both ours and German. Occasionally a Hun shell 
ploughs the ground again ; all around is desolation ; trenches 
unrecognisable, trees cut to pieces, houses demolished; no 
recognisable bit remains of anything overground. Of the 
Huns' dug-outs many are intact; they are too deep to touch. 
In some their occupants lie dead, at another machine gun 
and gunner lie together, and close to them lies the toll they 
took before their destruction, for the machine-gun is the most 
important entity in this war. Eelics lay all around, but I 
could not bring myself to pick one up. Somehow they 
seemed to be the property of the dead; in any case, I came 
away and found the ambulance with a feeling that I could 
not do enough for men who had been through so much. I 
spent that night at work there, and three succeeding nights 
as well, from 6 at night till 6 next morning. Eac^h day 
I had my own work to do with the unit, and could not 
be with the wounded in the daytime ; but night was more 
important in any case. I do not know how many I would 
have seen and attended in the time, but a better lot of men 
I never met. Not a complaint, hardly a groan, a smile, and 
always " thank you." Eager when they could to tell how 
their regiments did, and universal in the opinion of their 
ofiBcers : " They are the best in the world," and I believe it. 
The men have always been led, not directed ; I have yet to 
meet out here an officer who shirked. One, as an example, 
was wounded, slightly I think; in any case he was dressed 
in the ambulance, and told to wait for a car to take him to 
hospital. He saw a few of his men go back to renew the 
attack. He went with them, and was killed. He dined 
with me a couple of days before, and gave me his gramophone 
to keep for him. He is only one of many such, and the men 
are the same. One boy 1 attended was wounded an hour 
before. He had a temperature. I asked him about it, and 
found he had felt badly, very badly, for two days, but, as he 
said — " 1 wanted to be with the boys," and he is a member of 
Kitchener's Army." Thank goodness, the boy will recover; 
he is one of the Division that first advanced and broke the 
line, all raw soldiers whom I saw myself march past the 



The Great Ofjcnsivc, Picanly. 190 

dead and past the wounded, singing " Keep the Home Fires 
Burning," not as they sing it on a hohday at home, but 
with the look and grit of men who would go through 
Hell for those same " Home fires." The Hun knows 
them now for what they are. He fights like the 
devil, but his number is up; he has known it cr 
his higher command has for many months, but his 
death will be slow; our guns out there sing a requiem 
for him as I write (guns of all calibres going continually 
night and day since June 25th), his life is a hell, or must 
be, but he fights in France, no one here looks for any sudden 
or dramatic victory; it will be slow, costly, certain, but well 
worth all, the longer he sticks to it the more of his brood 
will die as they or any such nation deserve to die, they made 
the war, designed its ghastly methods, and act up to them. 
An officer the other day, a prisoner under escort, in the 
village near by here, drew a bomb from his pocket and blew 
up some of his guard. This, when he had surrendered, and 
had no chance of escape — while in a trench in front of us 
lies a broken machine gun with its operator chained to it 
and dead. Both incidents are tj'pical of his chivalry. 

In weather we have had bad luck. It has not been very 
rainy, but dull with low clouds; bad, very bad, for observa- 
tion, and an army blinded is badly handicapped. To-day was 
better ; had we had clear weather all along our advance would 
have been more rapid. Our aviators are splendid. Scarcely 
a Hun has been allowed over our line since June 25th, while 
ours have (weather permitting) attacked, observed, destroyed 
captive balloons ; have been the eyes and antennae of our 
armies. I hope it will be clear to-morrow. I have written 
enough. You have, perhaps, seen it all in daily papers, but 
I felt I must write. I hope you will be able to read it. It is 
now 12 midnight. The Hun is, I think, counter-attacking, 
and if he is will buy success dearly. The hum of shells out 
there is constant, and I hear our machine guns going. The 
Daily Mail j\Iap is an excellent one; I enclose it — keep it for 
me — I can describe it later when I see you. 

I am well, was never better; give my love to Eileen, chil- 
dren and all, and write a line to me soon, or ask Eilfeen to. 
I always Hke to hear. 

Yours affectionately, 

Charlie, 



SANITAEY AND METEOEOLOGICAL NOTES. 

Vital Statistics. 
For four weeks ending Saturday, August 12, 1916. 

IRELAND. 
The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institu- 
tions from without the respective districts — registered in 
the week ended Saturday, August 12, 1916, in the Dublin 
Registration Area and the eighteen principal provincial Urban 
Districts of Ireland, was 13.8 per 1,000 of the aggregate 
population, which for the purposes of these returns is esti- 
mated at 1,122,268. The deaths from all causes registered 
in the week ended Saturday, August 12, and during the period 
of four weeks ended on that date, respectively, were equal to 
the following annual rates per 1,000 of the population: — 

Nineteen Town Districts, 13.8 and 13.5; Dublin Registra- 
tion Area, 16.5 and 15.0; Dublin City, 18.0 and 16.4; Belfast, 
11.6 and 12.8; Cork, 15.0 and 11.1; Londonderry, 13.0 and 
8.8; Limerick, 13.5 and 13.8; and Waterford, 9.5 and 13.8. 

The deaths from certain epidemic diseases — namely, enteric 
fever, typhus, small-pox, measles, scarlet fever, whooping- 
cough, diphtheria, dysentery, and diaiThoeal diseases — regis- 
tered in the 19 town districts during the week ended Saturday, 
August 12, were equal to an annual rate of 1.1 per 1,000. 
Among the 87 deaths from all causes in Belfast were 1 from 
measles, 1 from scarlet fever, and 3 (of children under 2 years) 
from diarrhcfia and enteritis. The 4 deaths from all causes 
in Lisburn included 1 death from enteric fever and 1 death 
from diarrhoea and enteritis in the case of a child under 2 
years. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock 
and Kjngstown. The population of the area is 397,000. 

In the Dublin Registration Area the births registered during 
,the week ended August 12 amounted to 181 — 93 boys and 88 
girls, and the deaths to 139 — 78 males and 61 females. 



Sanitary and Meteorological Notes. 201 

DEATHS. 

The deaths registered, omitting the deaths (numbering 13) 
of persons admitted into public institutions from h)calities 
outside the Area, represent an annual rate of mortality of 
16.5 per 1,000 of the population. During the thirty-two 
weeks ended with Saturday, August 12, the death-rate 
averaged 20.7, and was 1.3 below the mean rate for the cor- 
responding portions of the 10 years 1906-15. The rate for all 
deaths registered during the thirty-two weeks was 22.2, and 
for the corresponding period of the preceding 10 years it had 
been 23.2. 

The 126 deaths appertaining to the Area included 1 from 
enteric fever, 1 from scarlet fever, 1 from whooping-cough, 11 
of children under 2 years of age from diarrhoea and enteritis. 
In the three preceding weeks deaths from enteric fever had 
numbered 0,0, and 1 ; from diarrhoea and enteritis of children 
under 2 years, 2, 4, and 3. No deaths from scarlet fever or 
from whooping-cough had been recorded in the three pre- 
ceding weeks. 

Tuberculosis caused 23 deaths, as against 23, 18, and 20, 
respectively', in the three weeks preceding. Of the 23 deaths 
ascribed to tuberculosis, 18 were referred to pulmonary tuber- 
culosis, 4 to tubercular meningitis, and 1 to abdominal tuber- 
culosis. 

Seven deaths were caused by cancer, 5 by pneumonia 
(2 by broncho-pneumonia and 3 by lobar pneumonia), 14 by 
organic diseases of the heart, and 3 by bronchitis. 

Among deaths of infants under one year old, 1 was ascribed 
to congenital malformation, 2 to prematurity, 5 to congenital 
debility, and 2 to convulsions. 

Six deaths were due to violence, of which 3 were caused 
by drowning, 1 bj' gunshot wounds, and 1 by a van. 

Thirty-five of the deaths appertaining to the Area registered 
during the week were of children under 5 years of age, 
20 being infants under one year, of whom 8 were under one 
month old. 

Of the 126 deaths recorded, 57 occuiTed in hospitals and 
other public institutions. 

STATE OF INFECTIOUS DISEASE. 
The following returns of the number of cases of Infectious 
Diseases notified under the " Infectious Diseases Notifica- 



202 



Scmitary and Meteorological Notes. 



tion Act, 1889," and the " Tuberculosis Prevention (Ireland) 
Act, 1908," have been furnished by the respective sanitary 
authorities : — 

Table I.— Showing the Number of Cases of Infectious Diseases notified in the 
Dublin Registration Area— (viz., the City of Dubhn and the Urban Districts of 
Rathmines and Rathgar, Pembroke, Blackrocii and Kingstown), and in the Cities 
of Belfast, Cork, Londonderry, Limerick, and Waterford, during the week ended 
12th August, 1916, and each of the preceding three weeks. 
A dash ( — ) denotes that the disease in question is not notifiable in the District. 



CiTiKS AMI) Week 
lIllHAN Disriiicis eiKiins; 


— 
1 


Rubella or Epiclemii 
Uose Uiisli 

Scarlet Fever 


p. 
>, 


be 

a 

D3 


2 
5 


o 

|g 

'^ o 

s5 


c 
c _ 
'SLs 






fa 
2 

p. 


Whcoping-cough 

Cerebro-spinal 
Fever 


- C 

2 


.52 

_c 

r^ - 

li 

3 


i 


City of Dublin 

RiilliininaH and ( 
Uatligar 1 

DiHtriot I, 

Penil)roke ( 
Urliaii -^ 
District 

BlackrocU j 
DJHtricl 1 

Kingstown | 
Urban J 
District 1 

City of Belfast 1 

City of Cork J 

City of London- 1 
derry | 

City of Liinciick -' 
CltycfWntcrfo,<l ] 


July 22 
July 211 
Aug. 5 
Aug. 1-.' 

July 23 
July 2!) 
Aug. 6 
Aug. 12 

July 22 
July 20 
Aug 5 
Aug. 12 

July 22 
July 2ii 
Auit. -'> 
Aug. 12 

July 22 
July 2!i 
Aug. 6 
Aug. 12 

July 22 
July 2;i 
Aug. 6 
Aug. 12 

July 22 
July 211 
Aug 5 
Aug. 12 

.luly 22 
July 211 
Aug. 5 
Aug 12 

July 22 

July 2!l 
Aug. .'. 
Aug. 12 

July 2? 
July 211 
Aug. r, 
Aug. 12 


6 

8 
2 

y 

1 


' 


7 
6 
5 
4 

\^ 
1 

10 
10 
18 
6 

1 
2 

1 

3 

8 
3 
;! 
2 


2 
2 




8 
5 
5 

1 

3 

4 

1 

3 
1 

2 

3 

1 
1 
1 


• 


. 


4 
2 

5 

1 
1 

1 

1 
1 


2 

1 
3 
3 

i 

I 

1 
1 


i 

1 
1 


1 
3 

2 


- 


2 
4 
8 
8 


17 
24 
!4 
10 

1 
1 


37 

24 
2 

11 

5 
U 

i 

1 

16 
17 
21 
11 

7 
116 

'Jc 
\0d 

2 

1 

4 
4 

» 
2 

1 
1 

1 



a Continucil fever. b Not Including 2 caaes of varicella. c Not including 3 cases of varicella and one of 
CL'rcbri>-Hi)iiial lever. d Not Inclu'Mug one case of cerebro-6t>lnnl fever. 



Sanitary and Meteorological l^otes. 



203 



Cases of Infectious Diseases under Treatment in Dublin 
Hospitals. 

Table 11. exhibits the number of cases of certain infectious 
diseases treated in the Dublin Hospitals during the week 
ended August 12, 1010, and the number under treatment at 
the close of each of the three preceding weeks. 

Table II. 





No. of Cases in Hospital : 






1 


Diseases 


at close of Avoek ended 


Wcel 


■i ended Aug. 1 


■) 














No. 
















under 










No. 


Dis- 


Died 


treat- | 




July 22 


July 29 


Aug. 5 


admitted 


charged 




ment 
at close 
















of week 

1 

) 


Enteric Fevi;r 


23 


21 


15 


7 


1 


— 


1 
21 


Typhus - 


2 


— 


— 


— 


— 


— 


— 


Small-pox - 


— 


— 


— 


— 


— 


— 


— 


Measles — 


25 


f2 


17 


6 


12 


— 


11 


Scarlet Fever 


59 


55 


46 


9 


8 


1 


46a 


Diphtheria - 


22 


21 


24 


7 


1 


— 


30 


Pneumonia - 


7 


9 


11 


4 


4 


— 


11 



a Exclusive of 13 patients in " Beneavin," the Convalescent Home of Cork 
Street Fever Hospital, 



From this Table it appears that the cases admitted to 
hospital during the week ended August 12, and the cases 
under treatment at its close, respectively, were as follows : — 
Enteric fever, 7 and 21; measles, 6 and 11; scarlet fever, 9 
and 46; and diphtheria, 7 and 30. Four cases of pneumonia 
were admitted during the week and 11 remained under treat- 
ment at its close. Of the deaths in hospital during the week 
one was from scarlet fever. 



204 Sanitary and Meteorological Notes. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, August 12, in 
96 large English towns (including London, in which the raLe 
was 10.6), was equal to an average annual death rate of 10.6 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland was 12.2 per 1,000, the rate for Glasgow 
being 11.9, and that for Edinburgh 12.5. 

Infectious Diseases in Edinburgh. 

The Eegistrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for 
Edinburgh, with a copy of his Eeturn of Infectious Diseases 
notified during the week ended August 12. From this Report 
it appears that of 42 cases notified, 20 were of scarlet fever, 10 
of pulmonary tubei'culosis, 6 of erysipelas, 5 of diphtheria, and 
1 of cerebro-spinal fever. Among the 390 cases of infectious 
diseases in hospital at the close of the week were 153 of pul- 
monary tuberculosis, 137 of scarlet fever, 57 of diphtheria, 
10 of measles, 5 of cerebro-spinal fever, 4 of erysipelas, 4 of 
enteric fever, and 1 of whooping-cough. 



Meteorology. 

Abstract of Observations made in the City of Dublin, Lat. 53° 20' 

N., Long. 6° 15' W., for the Month of Jidy, 1916. 
Mean Height of Barometer, - - - 30.045 inches. 

Maximal Height of Barometer (29th, at 9 a.m.), 30.417 „ 
Minimal Height of Barometer (7th, at 9 a.m.), 29.551 ,, 
Mean Dry-bulb Temperature, - - - 58.9°. 

Mean Wet-bulb Temperature, - - 56.5°. 

Mean Dew-point Temperature, - - 54.3°. 

Mean p]lastic Force (Tension) of Aqueous Vapour, .423 inch. 
Mean Humidity, . - - - 85.2 per cent. 

Highest Temperature in Shade (on 23rd), - 75.6°. 
Lowest Temperature in Shade (on 8th & 9th), 47.0°. 
Lowest Temperature on Grass (Radiation) (8th), 44.0°. 
Mean Amount of Cloud, - - - 64.4 per cent. 

Rainfall (on 13 days), - - - 2.139 inches. 

Greatest Daily Rainfall (on 1st), - - .425 inch. 

General Directions of Wind, - - W., N.W., N.E., E. 



Satiitdry ayid Meteorological Notes. 205 

Bemarks. 

July, 1916, presented two remarkably divergent types of 
weather — very sharply defined, the one from the other. 

Opening with a day of gloom, heav}^ rain, brisk N.E. to W. 
winds, and a low temperature (49.0° to 57.8°), the month was 
characterised by dull, cold, and rainy weather until the 13th. 
During that period, winds from polar quarters were in the 
ascendant, shallow atmospheric depressions drifting slowly 
eastward across the British Islands and showing an unusual 
tendency to halt and hover over the North Sea. In Dublin 
rain fell on 10 of the first twelve days, the measurement being 
2.035 inches, or 95.3 per cent, of the total precipitation of the 
month. The mean temperature for the same period was about 
5 degrees below the average for July. 

With the advance from the Atlantic of a large area of high 
atmospheric pressure, which developed much staying power, 
the weather began to improve first in Ireland and later in 
Great Britain also. After a few cloudy but otherwise fine days 
summer at length arrived, and on 9 out of the last 12 days the 
thermometer rose above 70° in the screen in Dublin. Sunday, 
the 23rd, and Sunday, the 30th, were particular!}' warm days^ 
the arithmetical mean temperature of the 23rd being 66.4° and 
of the 30th 67.7°. After the 12th, the rainfall in Dublin was 
only 0.104 inch on 3 rain-daj's. 

A noteworthy, though temj)orary, break in the providential 
spell of summer weather took place on Monday, the 24th, 
when violent and destructive thunderstorms, accompanied by 
torrential rains in many districts, prevailed over the greater 
part of Ireland. That day was dull throughout and absolutely 
cold in the London area, the highest temperature being 61°, 
and the sky remaining densely overcast till late in the evening. 

In Dubhn the arithmetical mean temperature (60.2°) was 
0.3° below the average of the 35 years, 1871-1905 (60.5°) ; the 
mean dry-bulb readings at 9 a.m. and 9 p.m. were 58.9°. In 
the fifty years ending with 1915, July was coldest in 1879 
(" the cold year ") (M. T. = 57.2°). It was warmest in 1905 
(M. T. = 63.8°) ; and in 1887 (M. T. = 63.7°). In 1913 the 
M. T. was 60.5°; in 1914, 60.0°, and in 1915, 58.1°. 

The mean height of the barometer was 30.045 inches, or 
0.130 inch above the corrected average value for July — namely, 
29,915 inches. The mercury rose to 30.417 inches at 9 a.m. 



206 Sanitary and Meteorological Notes. 

of the 29th, havmg fallen to 29.551 inches at 9 a.m, of the 7th. 
The observed range of atmospheric pressure was, therefore, 
0.866 inch. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 58.9°, or 6.7° 
above the value for June, 1916. Using the formula Mean 
Temp. = Min. + {Max. — Min.) X .465, the value was 59.7°, 
or 0.4° below the average mean temperature for July, calcu- 
lated in the same way, in the thirty-five years, 1871-1905, 
inclusive (60.1°). The arithmetical mean of the maximal and 
minimal readings was 60.2°, compared with a thirty-five years' 
average of 60.5°. On the 23rd the thermometer in the screen 
rose to 75.6° — wind, E. ; on the 8th and again on the 9th the 
screened thermometer fell to 47.0° — wind, N.W. to W. The 
minimum on the grass was 44.0°, on the 8th. 

The rainfall was 2.139 inches, distributed over 13 days. 
The average rainfall for July in the thirty -five years, 1871-1905, 
inclusive, was 2.680 inches, and the average number of rain- 
days was 17. The rainfall, therefore, and also the rain-days 
were below the average. In 1880 the rainfall in July was very 
large — 6.087 inches on 24 days ; in 1896, also, 5.474 inches fell 
on 18 days. On the other hand, in 1870, only .539 inch was 
measured on 8 days ; in 1869 the fall was only .739 inch on 
9 days ; and in 1868 .741 inch fell on but 5 days. In 1915, 
5.775 inches fell on 24 days. 

High winds were noted in Dublin on only 4 days. Tempera- 
ture reached or exceeded 70° in the screen on 9 days (all after 
the 19th), compared with only 1 day in 1915, 3 days in 1914, 
5 days in 1913, 4 days in 1912, 21 days in 1911, 4 days in 1910, 
3 daj^s in 1909, 9 days in 1908 and also in 1907, 10 in 1906, 
17 in 1905, and 10 in 1904. The thermometer failed to reach 
60° on the 1st, 2nd and 10th. 

Thunder occurred on the afternoon of the 24th. There was 
a solar halo on the 21st. Slight fog prevailed on the 22nd 
and 25th. 

The rainfall in Dublin during the seven months ending July 
31st amounted to 19.150 inches on 136 days, compared with 
16.882 inches on 118 days in 1915, 11.244 inches on 114 days 
in 1914, 15.731 inches on 117 days in 1913, 16.811 inches on 
27 days in 1912, 10.723 inches on 94 days in 1911, 21.032 
inches on 127 days in 1910, 15.377 inclies on 106 days in 1909, 



Sanitary and Meteorological Notes. 207 

13.809 inches on 120 days in 1908, 14.358 inches on 127 days 
in 1907, 13.664 inches on 122 days in 1906, 11.022 inches on 
109 days in 1905, 13.905 inches on 117 days in 1904, 1.072 
inches on 131 days in 1903, 15.507 inches on 115 days in 1902, 
11.432 inches on 93 days in 1901, only 7.935 inches on 80 days 
in 1887, and a thirty-five years' (1871-1905) average of 14.710 
inches on 113 davs. 



At the Normal Climatological Station in Trinity College, 
Dublin, the observer, Mr. T. Mulock Bentley, reports that the 
mean value of the readings of the dry-bulb thermometer at 
9 a.m. and 9 p.m. was 60. 0^ The arithmetical mean of the 
daily maximal and minimal temperatures was 59.6°, the mean 
maximum being 66.9"^ and the mean minimum 52.2°. The 
screened thermometers rose to 79° on the 22nd and fell to 
45° on the 8th and 18th. On the 1st and 18th the grass 
minimum was 39°. Rain fell on 11 days to the amount of 
1.938 inches, the greatest fall in 24 hours being 0.474 inch 
on the 1st. The duration of bright sunshine, according to the 
Campbell-Stokes recorder, was 142.5 hours, of which 11.5 
hours occurred on the 23rd. The mean daily duration was 
4.6 hours. In Juty, 1904, there were 201 hours of bright 
sunshme ; in 1905, 162.2 hours ; in 1906, 184.8 hours ; in 1907, 
178.1 hours ; in 1908, 174.3 hours ; in 1909, 139.8 hours ; in 
1910, 205.0 hours : in 1911, 221.8 hours ; in 1912, 153.0 hours ; 
in 1913, 157.2 hours ;in 1914, 147.7 hours, and in 1915, 117.7 
hours. The mean sub-soil temperatures at 9 a.m. were — 
at 1 ft., 60.5° ; at 4 ft., 56.1°. 



Captain Edward Taylor, D.L , recorded a rainfall of 1.85 
inches on 13 daj^s at Ardgillan, Balbriggan, Co. Dubhn. This 
measurement was 0.91 inch below the average and the rain- 
days were 2 m defect. The largest rainfall in 24 hours was 
0.66 inch on the 1st. The July rainfall at Ardgillan in recent 
years has ranged from 7.03 inches on 18 days in 1896 to 
0.52 inch on 5 daj-s in 1898. Since January 1, 1916, 18.87 
inches of rain have fallen at Ardgillan on 135 da3^s, the pre- 
cipitation being 3.66 inches over the average and the rain-days 
28 in excess. The shade temperature in July ranged from 
74.5° on the 30th to 44.3° on the 18th. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co, Dublin, was 1,64 inches on 13 days. The 



208 Sanitary and Meteorological Notes. 

largest daily fall was 0.34 inch on the 1st. The average July 
rainfall at Malahide in the 12 years ended with 1915 was 2.47 
inches on 16 days. 

The rainfall at Stirling, Clonee, Co. Meath, according to 
Mr. J. Pilkington's return, was 2.24 inches on 13 days, the 
largest fall on anyone day being 0.52 inch on the 1st. On the 
12th, 0.35 inch fell. After the 12th only light showers fell on 
3 occasions at night, the measurement being 0.14 inch. From 
January 1st to July 31st, 21.14 inches of rain fell on 138 days 
at Stirling. 

At the Ordnance Survey Office, Phoenix Park, rain fell on 
15 days to the amount of 2.41 inches (61.1 mm.), the greatest 
rainfall in the 24 hours being 0.65 inch (16.5 mm.) on the 1st. 
The total duration of bright sunshine was 146.6 hours, the 
greatest daily sunshine being 12.3 hour.3 on the 22nd. The 
thermometer rose to 76.2° in the screen on the 23rd, and fell 
to 42.6° on the 18th. The grass minimum was 34.0° on the 1st. 

Miss Mary Love reports a rainfall of 3 .86 inches on 15 days 
at Cheeverstown Convalescent Home, Clondalkin, Co. Dubhn. 
The heaviest fall in 24 hours was 0.72 inch on the 4th. 

Mr. F. Dudley Joynt recorded a rainfall of 2.060 inches on 
12 days at 89 Anglesea Road, Donnybrook, Dublin. The 
greatest fall in 24 hours was 0.385 inch, which occurred on 
the 6th. The thermometer rose to 77° on the 30th, having 
fallen to 48° on the 7th and 17th. 

Dr. Arthur S. Goff reports that at Belfort House, Dundrum, 
Co. Dublin, the rainfall was 1.64 inches on 20 days. The 
maximal fall in 24 hours was 0.39 inch, measured on the 1st. 
The mean temperature was 61.1°, the range being from 81° 
on the 23rd to 47° on the 8th. 

At Marino, Killiney, Co. Dubhn, Mr. W. J. M'Cabe, observer 
for the Right Hon. Laurence Waldron, D.L., registered a 
rainfall of 1.28 inches on 11 days, the heaviest fall in 24 
hours being .40 inch on the 1st. The average rainfall in July 
in the twenty-four years, 1885-1908, at Killiney (Cloncevin) 
was 2.408 inches on 15 days. 

Mr. Harold Fayle forwards the following weather report 
for July from Rosedale, Shankill, Dublin : — 

Mean Maximal Temperature, - - - 65.0°. 

Mean Minimal Temperature. - - - 51,8°. 



Sanitary and Meteorological Notes. 209 

Arithmetical Mean Temperature, - - 58. 4"^. 

Highest Temperature in Screen (23rd), - 72^. 

Lowest Temperature in Screen (1st), - - 46°. 

Lowest Temperature on Grass (1st), - - 34°. 

Nights of Ground Frosts , - - - 0. 

Rainfall (on 13 days). - . . 1.80 inches. 

Greatest Daity Rainfall (1st), - - - 0.53 inch. 

During the seven months ended July 31st, 1916, 20.26 
inches of rain fell on 130 days at Rosedale. 

At Auburn, Greystones. Co. Wicklow, "Miss E. E. M. Moore 
(for IMrs. Sydne}' O'Sullivan) recorded a rainfall of 1.922 inches 
on 12 days, the largest measurement m 24 hours being 0.910 
inch on the 6th. 

Dr. John H. ^I. Ai'mstrong, M.B., reports that the rainfall 
at Coolagad, Greystones, Co. Wicklow, was 2.04 inches on 
12 days, tlie maximal daily fall being 0.80 inch on the 6th. 
Since January 1, 1916, the rainfall at that station equals 
23.91 inches on 135 days. Distant thunder was heard towards 
X.W. at 1 45 p.m. and 3 p.m. of the 24th. The Welsh moun- 
tains were seen at 4 15 p.m. of the 8th. The thermometer rose 
to 72^ on the 26th and fell to 50" on the 17th. Fog prevailed 
during the afternoon and evening of the 3rd. 

At the Royal National Hospital for Consumption for 
Ireland. Newcastle, Co. Wicklow, Dr. Francis O'B. Kennedy, 
M.D., Resident Medical Superintendent, reports a rainfall of 
0.72 inch on 13 daj^s, the greatest daily rainfall being 0.24 
inch on the 2nd. The screened thermometers rose to 75° 
on the 26th and fell to 48° on the 10th. The mean maximal 
temperature Avas 65.0°, the mean minimum was 53.0°, and the 
mean temperature 59.0°. 

At the Rectory, Dunmanway, Co. Cork, the Rev. Canon 
Arthur Wilson, B.A., recorded a rainfall of only 0.78 inch on 9 
daj's. The rainfall was 2.76 inches under the average for July. 
The hea\'iest falls in 24 hours were 0.22 inch on the 11th and 
0.14 inch on the 5th. No rain fell at Dunmanway after the 
15th. The first ten days of the month were cool for July. 
The weather then began to become very warm, and from the 
14th onwards to the end it was very hot, especially on the 
23rd and 31st. Thunder was heard on the evening of the 
23rd, but no rain fell at Dunmanway, although there was a 

p 



210 Royal Medical Benevolent Fund. 

heavy downpour in the City of Cork and other parts of the 
count3^ The rainfall at Dunnianway for the 7 completed 
months of 1916 amounts to 28.06 inches, compared with an 
average of 32.23 inches. It was therefore 4.17 inches in defect. 
As a rvile the rainfall at Dunnianway in July is less than that 
in any other month, and the past month has recovered its 
position as the driest month of the year on an average of 12 
years. July, 1915, had been the wettest July which had 
occurred in eleven years. The rainfall of that month was 
7.37 inches on 21 days. 



EOYAL MEDICAL BENEVOLENT FUND. 

To the Editors of The Dublin Journal Or' ^Medical Science. 

31 Chandos Street, 

Cavendish Square, 

London, W., July 3, 1916. 
Dear Sirs, 

The Eoyal Medical Benevolent Fund, the great Bene- 
volent Society' of the ]\ledical Profession, is sorely in want 
of money now. 

Though in ordinary times the medical profession supports 
its own poor, in these war times this is no longer possible. 
At the May meeting the Committee had a balance of only 
£17 in hand, and at the June meeting was faced with a 
deficit of £16. The demands were heavy, and had to be met, 
and this could be done only by withdrawing £500 from the 
bank. 

As the direct outcome of the War, not only are the ordinary 
cases of poverty greatly increased in number, but an entirely 
new class of case has arisen urgently requiring relief, in 
which, without actual poverty, there is great temporary dis- 
tress — distress, however, which it is hoped will relieve itself 
soon after the War is over and the doctors serving return to 
their civil duties. 

At the outbreak of the War, the medical profession re- 
spoiulod freely to the Nation's call. The Territorial ]\Iedi- 
cal Officers were at once called out, and other medical men 
volunteered. Both alike had to leave their practice at very 



Royal Medical Benevolent Fund. 211 

short notice, and often without being able to make adequate 
provision for its continuance and maintenance during their 
absence. Their pay went but little way to supply the loss 
which their absence entailed, for the working expenses of the 
practice could not be materially reduced. The result was 
that many families fgund themselves in very straitened cir- 
cumstances. Eent, rates and insurance brook no delay, but, 
worst of all, school bills could not be paid, and if help had 
not been quickly forthcoming, the children would have 
suffered for the patriotism of their fathers. 

The following are typical of the cases with which our Fund 
has had to deal : — 

" A young doctor who had only been in practice a few 
years volunteered for Service, and was killed in action a few 
days later. He left a widow, aged 35, with two young boys, 
aged 3| and one year, entirely without means. The Fund 
voted £25 for her immediate necessities, and put her into 
communication with the Officers' Families Association, which 
gave further help." 

" A practitioner, aged 38, earning £700 to £800, volunteered 
for Service, leaving his practice in the hands of a neighbour, 
who was not a success. There were two young children, and 
another baby was born shortly after the husband left. The 
wife contracted pneumonia, and nearly died. A resident 
patient had to leave the house. Rent and other expenses led 
to a debt of about £80. This the doctor could not meet, and 
he huiTied back from the trenches to save his home from 
being sold up. The Fund voted £25, the Guild gave £15, 
the Officers' Families Association £25, and the Professional 
Classes War Relief Council further help, with the result that 
he returned to the front with his immediate anxieties re- 
lieved." 

" A captain of the Territorials was called out, and had to 
leave his practice in the hands of a locum, who proved a 
failure. There were seven children, aged 2 to 14. Financial 
difficulties arose, and payment of the school fees became im- 
possible. Between the Fund and Guild and Officers' Families 
Association the necessary fees were raised, and clothing, 
which was greatly required, provided." 



212 Eoyal Medical Benevolent Fund. 

These cases show well the way in which the Fund works — 
not only by giving relief itself in money and kind, but also by 
obtaining, through co-operation with other Benevolent Socie- 
ties, more substantial assistance than it could afford alone. 

But there is another class in which the distress is, perhaps, 
even greater and adequate relief more difficult. It is that of 
men who left home and a good practice in vigorous health 
and who have come back, crippled by wounds or with health 
impaired, to a practice severely damaged by their absence, 
and without the strength or energy to regain the practice and 
jDosition which they sacrificed. 

Our Fund has set apart a special sum to meet emergency 
claims of this kind, yet the demands are so great that it will 
soon be exhausted. We cannot now rely on the profession 
alone to supplement it largely ; for the INIedical Profession, 
like all other professions, is hit very hard by the war, and 
has no longer its old resources to draw upon. 

What is required is an Emergency Fund large enough to 
deal adequately with these emergency cases arising directly 
out of the war, and for this we are driven to appeal to the 
public as well as to our own profession. 

We trust that our appeal will meet with a liberal response, 
both from the public and from the Medical Profession, for, 
unless fresh funds are quickly forthcoming, it will be im- 
possible to continue the relief which is so urgenth' required. 

We are, 

Faithfull}' yours, 

JOHN TWEEDY, President. 
SAMUEL WEST, Hon. Treasurer. 
G. NEWTON PITT, Hon. Secretary. 



THE DUBLIN JOURNAL 



OP 



MEDICAL SCIENCE. 

OCTOBER 2, 1916. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. XL — The Prophylaxifi of Venereal Disease.'^ 
By Thomas D. Power, M.D., B.Ch., B.A.O., B.A., 
Univ. Dnbl. ; Temporary Surgeon, R.N., H.M.S. 
" Zealandia." 

There are few subjects relating to the hygienic welfare of 
the nations concerned to which more attention has been 
paid throughout Europe during the last half decade than 
the question of the spread of venereal disease. The matter 
appears to have first gained prominence in connection with 
the various military organisations of the different countries, 
and as a consequence it has come to be recognised as a 
subject of the most vital importance to the civil population 
of every European State. It has been the theme of Com- 
mission after Commission throughout the world even in our 
own time, and there are few diseases where patient 
scientific research has reaped more plentiful rewards in 
the shape of accurate diagnosis and treatment. 

In order better to discuss the prophylaxis of venereal 

* A Thesis road for tho Degree of Doctor of Medicine in the 
University of Dublin, June, 1916. 

VOL, CXLII. — No. 538, THTBP SERIES, Q 



214 The Prophylaxis of Venereal Disease. 

diseases it will perhaps be permissible to devote some little 
time to a synopsis of the natm-e and cause of these com- 
plaints ; for in the recognition of the cause is the prevention 
thereof. Under the heading "Venereal Diseases" are 
grouped syphilis, gonorrhoea, and the ravages of the bacil- 
lus of Ducrey. Syphilis and gonorrhoea are tvi^o contagious 
diseases transmitted from person to person by direct 
contact, usually in the act of sexual intercourse. 
They may also be acquired innocently, but (apart from 
congenital transmission) this is not a common occurrence. 
Syphilis appears to have been unknown in Europe before 
the year 1493, when it is supposed to have been introduced 
into Spain by Columbus' crew. Since that time it has 
been rampant throughout the Continent, the tide of its 
intensity ebbing and flowing with the varying economic 
conditions. No nation appears entirely immune, though 
agricultural communities alwavs fare best. The disease 
can be transmitted to young and old alike, and the liability 
of the offspring to be contaminated constitutes one of its 
most aggressive features. 

There appears to be little doubt as to the prevalence of 
syphilis in Great Britain at the present time, though the 
inaccuracy of civil statistics renders it impossible to state 
whether the disease is on the increase or otherwise. Greater 
reliance, however, can be placed on the Army and Navy 
returns, and these show a decrease in the prevalence of the, 
disease during recent years. Thus, in 1888 the incidence 
of venereal disease in the Army was •22'2.5 cases per 1,000, 
but in 1912 it had fallen to 56.5 cases per 1,000. The 
Navy, on the other hand, showed a statistical return of 
48.92 cases per 1 ,000 in 1V)05, and this was reduced to 28.93 
per 1,000 in 1912. This marked decrease in the prevalence 
of syphilis in the Services is most gratifying, and renders 
it worth while making a short analysis of the causes 
operating to bring it about. The Navy and Army have 
greater facilities than civil bodies for estimating the value 
of any preventive measures adopted, and this power they 
have utilised to the full, with the aforementioned excellent 
results, 



By SrR<iKON Power, H.N. 215 

Syphilis and gonorrhcea are essentially diseases of 
irregular sexual intercourse ; it is therefore certain that as 
long as man gives free vent to the passions which he pos- 
sesses, and w^hich it is right for him to possess, he will 
run the risk of infecting; himself with one or other virus. 
The opinion was held for many years, and is still held by 
many, that incontinence is necessary and healthful. 
Young men were brought up with the idea that 
it is manly to get drunk and manly to be in- 
continent. There is no foundation for either theory ; 
continence is not only healthful but manly, inas- 
much as all forms of self-restraint are manly. There 
are large numbers of men, both clerical and civilian, 
who do practise continence, and they are physically no 
worse for doing so, provided they are engaged in healthy 
and busy occupations. Sir William Osier pointed out 
many years ago that hard physical exercise is the best anti- 
dote for the irregularities of the imagination and sensual 
affections consequent on a lazy sedentary life accompanied 
with overfeeding and luxury. Bearing these facts in mind, 
the officers of the Eoyal Army Medical Corps are doing 
everything in their power to check illicit intercourse by 
encouraging all outdoor games and by instituting courses 
of lectures on the dangers of contracting venereal disease. 
The value of these lectures is unquestionable, and they 
could be easily adopted as a means for combating the evil 
among the civil population. The points that should be 
elucidated are as follows : — 

(1) The nature and evil results of syphilis and gonorrhoea, 
with special emphasis on the disastrous effects these 
diseases exert on the next generation. Many men who 
were absolutely regardless of immediate personal con- 
sequences would ]iause and consider where others w'ere 
concerned. 

(2) It should be insisted that the only certain way to 
avoid infection is to keep out of harm's way. 

(3) Men should be urged to seek immediate advice and 
treatment when they have the slightest suspicion that they 
have been infected. 



216 The Prophylaxis of Venereal Disease. 

If such a system of lectures were adopted universally, 
there can be little doubt that enormous good would result. 
The amount of venereal disease that is contracted through 
sheer ignorance is beyond conception, and the fallacy that 
only professional prostitutes are dangerous has led many a 
man to his fate. Young women and girls should also 
receive some instruction in matters sexual, and much good 
work has already been done with this object by the National 
Council for the Prevention of Venereal Disease. 

We have thus seen that increased education in such 
matters is considered by the Naval and Military Authorities 
to be an asset of considerable importance in the reduction 
of the incidence of venereal disease. Of equal, if not of 
greater, significance is the matter of sobriety. A man 
under the influence of drink is more liable to contract 
venereal disease for two reasons : 

(1) He loses his self-control and judgment. 

(2) The condition lowers his physical resistance, 
rendering him an easier prey to the gonococcus 
or spirochsete. 

During the last few years there has been a great wave 
of temperance throughout all His Majesty's Forces, both 
Naval and Military. The causes of this movement do not 
concern us — whether it be due to the increased prominence 
given to games, the better education of the lower classes, 
or the work of the various religious organisations. Let it 
suffice that such a wave of sobriety does exist, and its re- 
sults in connection with venereal disease are most manifest 
and encouraging. 

We now come to the subject of preventives. The ques- 
tion of the encouragement of the use of preventives as 
a means for combating sy]ihilis and gonorrhoea is one 
around which a fierce controversy has been raging for many 
years. The subject jiresents grave difficulties owing to the 
ethical and moral problems which are involved in its con- 
sideration. As is usual in such discussions, the solution 
for the difficulty lies in a mean between the two extremes, 
but it is somewhat difficult to bring this point before the 



By Surgeon towEB, t{..lSf. 217 

general public. Metchnikoff has shown that a 25 per cent, 
calomel ointment apjilied to the affected part within 
twenty-fonr hours of infection will obviate the risk of con- 
tracting syphilis. It has also been demonstrated that a 
sufficiently strong silver salt acts in the same way with 
regard to the gonococciis. Of the efficacy of these methods 
of prophylaxis I am convinced. 

About the year 1910 the Admiralty issued to ships large 
supplies of calomel cream 33 [)er cent., and a jelly known 
as nargol 2^ per cent., which is a chemical combination 
of silver with nucleinic acid. These were to be issued to 
men, if they demanded them, but no note was to be made 
of the names of those who i^resented themselves, and the 
matter was to be jierfectly voluntary. The jelly is run 
into collapsible tubes with nozzles suitable for intraurethral 
injection, and these, together with tubes of calomel cream, 
are issued in small and convenient cardboard boxes. The 
majority of the men avail themselves of these preparations 
whenever they are likely to require them, and I have had 
many different op^^ortunities of estimating their value. 

On one occasion, shortly after the evacuation of the Gal- 
lipoli Peninsula, the ship in wdiich this Thesis is being 
written put into Malta for a few days, and gave two nights' 
leave — the first that had been granted for nine months. 
During" these past nine months the ship's company had 
been through a time of considerable stress and strain, both 
in the North Sea and at the Dardanelles. Under such cir- 
cumstances it would be reasonable to ex[)ect that a sudden 
temporary relaxation of discipline would produce a high 
incidence of venereal disease on board. The result was 
quite the reverse ; three men alone out of 860 being in- 
fected — two with gonorrhoea and one with chancroid. 
Many other ships have had equally good results with these 
measures, and from a inirely scientific point of view their 
worth may be considered thoroughly established. Viewed 
from an ethical standpoint they are undoubtedly wrong, 
but into this question I do not propose to enter. 

Of the numerous mechanical methods of prophylaxis 



218 The Prophylaxis of Vcnercat Disease. 

there is little to be said beyond the fact that they can never 
be considered absolutely reliable. The liberal use of soap 
and water before and after intercourse, combined with a 
high standard of personal hygiene, would prove of con- 
siderable value if it were generally adopted ; but all artificial 
appliances, if not kept in perfect condition, are worse than 
useless. 

We now come to what I consider to be the most powerful 
weapon at our disposal for dealing with venereal disease, 
namely, the early diagnosis of syphilis. To speak of 

early diagnosis ' " as a " means of prevention ' ' may at 
first appear slightly paradoxical, but when it is pointed out 
that we are dealing with the commimity at large rather 
than with the individual, its application will be easily 
understood. 

In the recent report of the Royal Commission 
on Venereal Disease the following ])assage occurs : — 
" The lack of facilities for diagnosis undoubtedly 
accounts for the large amount of venereal disease, 
and particularly syphilis, which, not being recog- 
nised at an early stage, is inadequately treated or entirely 
neglected." This is only too true. Men who have con- 
tracted syphilis, but in whom it has not been recognised 
until secondary symptoms develoi), have probably, in a 
great many cases, passed on the infection to others before 
they are themselves aware of their complaint. Again, if 
syphilis is allowed to proceed to the secondary stage, all ihe 
secretions of the body beconie infective, thus rendering the 
disease even more contagious than it originally was. 

In the Navy in May, 1912, the proportion of cases of 
primary to secondary syphilis was 715 to 2,744, or a ratio 
of practically 1 to 4. Now all these cases of secondary sy- 
philis must have passed through a primary stage which has 
either been inadequately treated or gone undiagnosticated. 
We have, however, learnt by experience that the combined 
use of salvarsan and mercurial cream injections, if applied 
in the primary stage, are {)ractically certain preventives 
of any secondary lesions appearing. Allowing, therefore, 



By SruciEON 1V)\VKH, R.N. '219 

for a certain number of these secondary syphilitics being of 
old standing, we are driven to the unpleasant conclusion 
that a large proportion ol' cases have passed un- 
diagnosticated through the primary stage. If this 
is true in a Service where the cost of Wasser- 
manns and of microscopical examinations does not 
enter into our consideration, how much more so 
must it apply to civil conmiunities, especially among 
the poorer classes? The means at our disposal for making 
an early diagnosis of syphilis are two in number — (1) clini- 
cal, (;2) microscopical. With regard to the first of these 
methods, it may be remarked that the clinical signs of 
primary syphilis are often slight and very misleading. In 
a case with a history of an incubation [)eriod of from three 
to five weeks, and manifesting the typical hard chancre 
attended with bullet buboes in the groin, the matter presents 
little difficulty. On the other hand the classical Hunterian 
chancre does not appear to be as common as text-books 
lead us to believe. Almost any lesion appearing on the 
jieuis after exjiosure to infection may be the starting point 
of syphilis, and the matter is even more complicated by the 
occasional appearance of chancres in such regions as the 
anus, mouth, and hand. During four months spent in a 
parent ship for small craft, where plenty of leave was given 
and there were numerous opportunities of infection, I only 
on one or two occasions saw cases of syphilis beginning 
with the classical sore described by text-books. 

Now, as has been shown above, if we await the appear- 
ance of secondary symptoms before making a diagnosis of 
syphilis, we have not only increased the chances of spread- 
ing the disease but are delaying our treatment with " 606 " 
and mercury until the effectiveness of these drugs is 
greatly diminished. We therefore turn to the microscope 
for further information in this earlier stage. 

That the Spirochfete pallida of Schaudinn is the actual 
cause of syphilis has now been proved beyond all question, 
and the recognition of the organism in any suspicious lesion 
renders the diagnosis of syphilis certain. During the earlv 



220 The Prophylaxis of Venereal Disease. 

stages of the disease the organism is to be found in tlie 
superficial parts of the sore, or in the immediately surround- 
ing tissues, or in the lymphatic glands. A scraping from 
the sore, or a puncture m the case of the gland, when suit- 
ably prepared and examined under the microscope, ought 
to demonstrate the causative organism. Here a word of 
warning is necessary. It is useless to hunt for s[)irocha'tes 
in a sore which has been treated locally with mercury. The 
pathognomonic agent will in these cases have been driven 
into the deeper layers of the tissues, and will be impossible 
to find. Any suspicious sore should be dressed in gauze 
soaked in saline solution until a diagnosis has been arrived 
at. 

There are three chief methods of demonstrating the 
spirochgete under the microscope : 

(1) By the use of the ultra-microscope. This method 
is at present out of the reach of the ordinary practitioner, 
but the results it gives appear most satisfactory. It con- 
sists of passing rays of light through the specimen parallel 
to the surface of the slide. The field will appear absolutely 
dark except where the ray meets with an object, which 
causes it to be reflected in all directions. The object is 
thus seen as a brilliant spot on a black ground. 

(2) Burris' Indian ink method consists in applying an 
emulsion of fine particles of carbon. These settle down 
on either side of any organisms that may be present, so 
that the latter are seen as transparent bodies on a dark 
background. 

(3) The third method consists in applying different stains 
to the suspected matter. It is difficult and takes consider- 
able time, though in the hands of an expert the results are 
excellent. 

Of these three methods of demonstral ing the spirochtcte, 
Burris' Indian ink is the only one practicable for the aver- 
age medical man, and even this method is not very simjile 
owing to the difficulty of obtaining a thin enough smear. I 
have purposely avoided any mention of the Wassermann 
reaction in connection with early diagnosis ; when i)ositive, 



Cardiac Curves and Sounds. 221 

it is undoubtedly of value, but in many cases weeks elapse 
between the time of infection and the appearance of a 
positive Wassermann. 

It will be seen, therefore, that the early diagnosis of 
syphilis is to a great extent dependent on the laboratory 
expert ; the easier we can obtain the advice of a bacterio- 
logist, the greater is our chance of preventing the spread 
and checking tlie course of syphilis. In this lies the whole 
future of the prophylaxis of venereal disease ; the greater 
number of laboratories there are throughout the country 
attached to our smaller hospitals, the more easily shall we 
be able to combat the disease. Here, and here alone, can 
our legislative bodies help us. All other forms of adminis- 
trative interference have failed us in the past, as they are 
failing on the Continent at present. 

To sum up, the essence of the system that should be 
adopted is as follows : — The poorer classes should receive 
better education in matters sexual. It is foolish to object 
to such lectures on the grounds that they lower the general 
moral tone. The only possible effect they could have 
would be to instil into the minds of the next generation a 
healthier and saner attitude towards matters of the most 
vital importance to our national hygienic welfare. Human 
nature being what it is, we cannot let our efforts rest here. 
Every facility should be given throughout the country for 
the early diagnosis and free treatment of those infected 
without any disability or punishment being attached 
thereto. Adopting these measures, we may hope in time 
to considerably reduce the incidence of this terrible disease. 
Total immunity we shall probably never know, but we can 
at least direct our steps in the right direction. 

Art. XII. — Cardiac Curves and Sounds. By G. Arbour 
Stephens, M.D., B.S., B.Sc. (Lend.) ; Hon. Physi- 
cian, Royal Cambrian Institution for the Deaf. 

A FEW months ago a leading London specialist was 
endeavouring to impress me with his great knowledge 
concerning heart murmurs, and, by way of contrast, my 



2'22 Cardiac Curves and Sounds. 

provincial ignorance, when I took occasion to ask him 
" What was the amount of tlie intra-pericardial pres- 
sure? " 

His reply was to the effect that he tlid not know there 
w'as one, either positive or negative, to say nothing of the 
amount or of its effect on heart sounds. 

That the conditions luider which the intra-pericardial 
fluid exists should have escaped the attention of physio- 
logists as well as pathologists for such a long time is, to 
say the least, remarkable. 

My attention was drawn to the state of the pericardium 
and its contents when endeavouring to take some cardiac 
curves by means of an instrument that lias been called a 
" polygraph." It is a very jiretty instrument, over the 
construction of which a considerable amount of ingenuity 
has been expended, but unfortunately it is not reliable, 
like all pseudo-scientific instruments. 

It was wdiilst trying to draw deductions leased on its 
reliability that I realised the timer had a knack of being 
irregular, and 1 was on the point of ]xicking the instru- 
ment for mechanical attention and repairs when I thought 
it advisable to investigate the diagrams in Sir James 
Mackenzie's nicely got-up book, when lo ! to my amaze- 
ment, 1 found all liis diagrams affected in the same way 
as mine. 

This was, indeed, very awkward, h)r, when trying to 
follow his uiiiuite instruction for the analysis of a. Iracing. 
whcM'c one has to be careful to tenths of a second, and the 
instrument is out by 20 ])er cent., 1 found myself getting 
hopelessly confused. 

7n this c(jnfusion I made so bold as to write to Sir 
James Mackenzie, and pointed out the irregularities, to 
which he very kindly replied, stating that the irregulari- 
ties were of no importance, as they had been confirmed by 
a more scientifically correct instrument called the electro- 
cardiograph. 

Sncli an answer could hardly be described as comfort- 
ing, so I thought it advisable to find out for myself what 
it was that really did give rise to the tracings. 



By Dn. G. A is hoi: a Stephens. '2'23 

In the guide-book one finds it stated that — " The move- 
ments most readily recognised are: first, the apex beat; 
second, the filhng of the ventricles; third, the emptying 
of the ventricles; and fourth, the shock coimmmicated by 
tlie sudden hardening of the ventricular walls as they pass 
into systole"; so that this instrument rcicords move- 
ments, filling and shock — three distinct physical con- 
ditions — all at the same time; a really wonderful |)iece of 
mechanism ! 

But what is tlie apex beat? that is tht' (piestion to 
which Sir James Mackenzie readily answers — " Tlie for- 
cible outward projection of the apex of the heart during 
the ventricular systole," having apparently forgotten, 
however, his previous statement — " the other fixed point 
during contraction is the apex." 

Professor Haliburton is much more cautious, content- 
ing himself with — " Doubtless the apex beat is produced 
by the increased pressure on the aorta pressing the heart 
more closely against the chest walls." 

The President of the English Eoyal College of Physi- 
cians prefers the word "impulse," for he says: "The 
apex is external to the visible heart-beat." 

Peculiarly enough, both the cautious and the incautious 
agree that the heart knocks the chest wall at least 70 
times a minute, or 4,200 times an hour, yet mirabile dictii 
notwithstanding the bumps, there is no damage done to 
the heart, whereby some thickening or cornification takes 
place. 

If this bumping does really take place it is astonishing 
no fertile imagination has given rise to an explanation, 
but if it does not, the silence is golden. 

The heart is surrounded by the pericardium, which 
contains 20 to 80 cc. of fluid, and this must surely have 
some function. 

Let us consider under what conditions this fluid exists. 

At post-mortem examinations the learned operator care- 
fully makes an, incision in the fore part of the pericardium, 
looks curiously at its inside, and calls out : " A couple of 



224 Cardiac Curves and Sounds. 

ounces of fluid," and proceeds to the next item. These 
learned operators always find the fluid at the bottom of the 
sac, where gravity naturally places it, but had nature in- 
tended such a limited sphere of influence for the fluid we 
should have found, no doubt, a nicely evolved sac for its 
own use. 

No such limitation of function exists, for if the hearts 
of newly-slaughtered animals be felt through the peri- 
cardium no fluid is found at the bottom, but it exists all 
over the surface of the heart, and this fluid acts as a 
lubricant and buffer to jn'otect the heart from ' ' corns. 

How is the fluid kept in contact with the whole surface 
of the heart? The only answer that occurred to me was 
suction or negative pressure within the pericardial sac, 
and so, armed with spirit manometer and aspirating 
needle, I proceeded, in company with my friend, Mr. 
Kirkman, lecturer on physics, to the slaughterhouse to 
put my theory to the test, when we found an average 
negative })ressure of 3 to 4 per cent, of water. 

This little bit of information I thought worth while 
putting before a Fellow of the Royal Society, who kindly 
replied that there was nothing in it (not meaning thereby 
negative pressure but insignificance of importance). 

Three weeks afterwards he was good enough to recant, 
and thought " my notes seemed to prove that the peri- 
cardial factor had escaped the attention of others" — 
negative commendation for which, however, I wrote him 
my grateful thanks, contenting myself that Harvey took 
fourteen years to convince the College that the blood cir- 
culated. When the heart contracts and voids its san- 
guinary contents, its size must be reduced, and thereby 
the intra-pericardial space becomes increased, with an 
accompanying modification of its negative pressure. 

With the enlargement of the heart during diastole 
there is less room for the pericardial fiiiid, and one natur- 
ally asks has Ihis increased intra-pericardial pressure any- 
thing to do with the impulse? 

The receiver usually supplied with the polygraph is 



By Dr. G. Arbour Stephens. 225 

about one inch in diameter, but why one inch and not 
two or three inches? 

I forthwith proceeded to experiment, and with most 
interestino- results, as evidenced by the accompanying 
diagrams. 

A, B and C are taken from a man aged forty-one by 
means of receivers sized one, two and three inches in 



^''l^ rV^n^ ^r '\n 



v^.vt-jV^vj-f1ViV|,vi,^-lV.j^,v|V(v^ 



V 



diameter. They bear but very little resemblance to one 
another, and apart from time have very little in common. 

The ' ' ventricular push ' ' of the authorities applied at 
the lower end will hardly account for an apparently big 
push all over the cardiac area ! 

Figures D, E, F are taken from a little girl suffering 
from pericarditis with slight effusion. In this case there 



y^V\A^l^v^,.^^^^^--/v^,J^^.^^_^^^^^,^_^7v^^,^ 



rJ'^-'^-^rVjXjt-^j^'J'^'rv.jr^j^U^X^ 



226 



Cardiac Curvcfi and Sounds. 



is a greater amount of resemblance, but liere we are deal- 
ing" with a condition where the fluid contents of the peri- 
cardium are of great account. 

Are the tracings due to the waves of the intra-pericar- 
dial fluid? In this connection the diagram G, taken from 
a man aged forty-four, with marked pericardial effusion, 



is, T think, of great value, for it shows that there was 
little room for the formation of the usual type of pericar- 
dial fluid waves, whilst the heart sounds were not to be 
heard at all ! 

Diagram H was taken from a small rubber balloon 
filled with one drachm of water, and pressed periodically 
at one end bv the finger. T then replaced the polygraph 



receiver by the end of my stethoscope, and on listening 
I heard ]iroduced sounds identical with those of the 
heart. 

Are the heart sounds due to the movements of the peri- 
cardial fluid and not due to the contraction of the muscles 
of the organ? 

Is it allowable to ask such a question, or do I make too 
bold to question the most dogmatic of all professional 
authorities? 

Has anyone ever heard the soimd of n contracting 
muscle, or is the present generation prepared to swallow 
the shibbolethical bolus of a past age? 

Does anyone really believe that the contractions of the 
small fcEtal heart can be heard through the thick muscles 
of the enlarged uterus as well as the abdominal walls, 
especially after listening to the sounds produced by a 



So})iC Su(j(iestiot}s til Micro-Bioiiietricft. '227 

small quantity of water in a rubber tinger-stall, which is 
pressed periodically by the finger? 

As an alternative to external presure of the rubber 
balloon I have experimented w^ith one balloon inside 
another containing fluid, and the sounds produced by 
periodically increasing the distension of the inner one 
aie wonderfully exact reproductions of the sounds of the 
heart. 



Art. XIIT. — Soinc Suggestions in Micro-Biometrics. 
By Edwin Wooton, Author of " The Metabolism of 
Senile Decay," " Renal Excreta," and other Re- 
searches. 

Although the many improvements that recent years have 
witnessed in the methods and materia of microscopic study 
have given histology a high place among the sciences, and 
the visible characters of minute structures are matters of 
fairly advanced knowledge, there obtains a factor concern- 
ing which our teaching is crudely inchoate : the relativity 
of concrete quantities. 

Our text-books and monographs deal with these either 
by the metric or the ordinary arithmetical system. We 
are taught that a cell measures so many mikrons, or frac- 
tions of a millimetre or of an inch, linearly, superficially, 
or cubically. We are taught also in each case either that 
the measurements range from a stated figure to another, 
or we are given that most loathful compromise — an 
" average." 

When all these details have been tabulated, we see a 
series of quantities having no more apparent relation to 
one another than those in a shopkeeper's price list. So 
far as 1 am aware, it has never been advanced that they 
have an inter-ratio. They form a wilderness of crudities, 
and, for aught that a philosophical student can see to the 
contrary, they might be doubled, halved, or totally 
neglected without in the least affecting his acquaintance 
with the laws of life. 



228 Some Suggestions hi Micro-Biometrics. 

In the study of macro-biometrics we have at the very out- 
set the common knowledge that a normally formed human 
body has a certain number of legs, arms, fingers, toes, and 
other parts; that there are tall people and short people, 
bie" heads and small heads ; and our studies lead us to 
further certainties less obvious : the best ratios between 
bodily parts, and the conditions modifying such ratios. 

The entire study of biology conducts one at each step 
nearer to the belief that for each obtaining concrete fact 
there is a physical causation ; that beaks, fins, feathers, 
horns, poison glands, and cerebral convolutions are but the 
material consequences of responsive adjustments to cease- 
less stimuli ; and that as nothing obtains without a cause, 
so for each biological truth there is a purpose ; it is never 
in itself — finality. 

Then, how comes it that when dealing with tissue 
elements we have acted as if such lessons had never been 
learnt? Are we to think that while the length of a limb, 
the diameter of an ocular pupil, and the obtaining ratios 
of macro-structures in general result from law, the prin- 
ciple of proportion does not subsist between structural 
elements? Is not such a supposition a self-disproving 
absurdity? If true, it would be a solecism in nature. 
The coarser structure is but a product of structural tissue 
units, just as the chemical character of a ton of calcium- 
sulphide is an expression of its molecules. 

I submit that the chaos is a consequence of our methods 
of measurement obscuring the truth. 

These methods are purely arbitrary, and of necessity 
they give factitious results. It does not affect the question 
whether one uses tlie metric or, in this covmtry, the more 
popular system. In either case the calculations are arith- 
metical throughout, and Nature does not so work. 

One might as well attempt to solve the ])roblems of 
crystallography or chemistry by arithmetic as those of 
biology. Arithmetical computations are true only when the 
units dealt with progress arithmetically. Tf they progress 
geometrically, or by nniltiples, and no practical recognition 



■Ry Ed WIN Wootox. 229 

is extended to the fact, arithmetic becomes the mother of 
falsity. 

Had chemical philosophy never advanced beyond tlie 
arithmetical stage, where would its law of combining pro- 
portion be? — still in the secret archives of Nature. One 
may analyse an ounce or a ton of a compound and find so 
much of each constituent, and yet be totally in the dark 
as to there being any such law. He who would master 
even the simplest outlines of chemistry must seek for the 
units and ratios, as did the chemical discoverers — in 
chemistry itself. He may not bring to his study a method 
of computation foreign to it. 

Such considerations are equally true in physics. To 
the man unfamiliar with the laws of motion it seems the 
teaching of common sense that if a missile is discharged 
vertically at ten feet a second it will attain five hundred 
feet in fifty seconds. 

To work solely by arithmetic in any of the sciences that 
deal with laws of nature is to reason rightly on erroneous 
premises, w^ith, of course, error for consequence. 

Quite apart from such considerations, very grave objec- 
tions can be raised to the employment of our ordinary 
abstract quantities. All fractions are negative. A 
quantity that is to be handled, using a figure of speech, a 
score of times daily, that has to be clearly mentalised, and 
conveyed to the mentality of others, should be a positive 
unit or multiple of units, of which the mind can on the 
instant form a clear concept. What sort of idea is afforded 
by .000057 mm.? On paper it is nebulous, and verbally 
it is wasted breath. Inch fractions are equally useless. 
As specimens, take the diameters of a red and a white blood 
cell = 3iVo and o^sVo- The fact that they have no common 
denominator renders comparison mentally meaningless to 
those who have not worked out the ratio of the fractions. 

To a limited extent the introduction of the 
mikron has remedied the difficulty, so far as the 
metric system is concerned. But to get the right 
mental grip one should treat it and its multiples 



230 Some Suggestions in Micro-Biometrics. 

as positive. If we say, a thousand mikrons make a 
millimetre, and a thousand millimetres make one metre, 
we have materials for giving a clear mental picture of any 
linear measurement that has to be stated. But to do this 
effectively we need a concrete unit that the mikron shall 
represent, and hitherto not one has been suggested. 

The metric system is the best possible for multiples of 
the metre ; for fractions of the millimetre it is a complete 
failure. 

Inch fractions are almost unusable when teaching. Not 
seldom, one has to remind the pupil that the larger the 
denominator the smaller is the object. Sometimes these 
fractions crystallise grotesquely in a pupil's mind. The 
two cited above are examples. The unfortunate student, 
fogged by the thousand and one things he has to commit 
to memory, thinks of the cells as measuring thirty-two one- 
hundredths and twenty-five one-hundredths respectively ! 

Is there a true biological mode of progression operative 
in the human organism? 

We know, of course, that chemically the body works 
under ordinary chemical law, and that chemical progres- 
sion is by multiples of molecular weight, and we have no 
reason to suppose that in the microcosm the laws of physics 
are specifically modified. The progression, if it obtain, 
will be in all probability cytological. 

Yet, for the reason that the human body is a microcosm, 
exhibiting in all its modes of working the laws that govern 
the outer universe, it is only reasonable to expect that 
cytological progression — if a fact — will have impressed its 
character on every such law. We should expect to see in 
it^ electric, chemical, and other life factors some clue to 
inter-cellular ratio. 

Hence, the natural divisions for research are many. 
The relation of calorics to numerical cellular units, the 
relation of molecular weight to calorics, the electric poten- 
tial of muscle mass, and the relation of potential to cell 
number are but examples. 

As restricted time and limitation of space will not admit 



By Edwin Wooton. S31 

of anything even approachino- an exhaustive treatment of 
the subject, and as my aims are rather to exemphfy what 
I beheve to be truths than to adduce a huge mass of data, 
I shall deal only with a few salient facts, taken almost at 
hazard, from the host I have collated. In doing so, I 
would lay stress on the statement that I am unacquainted 
with a single fact inimical to the reasoning here advanced. 

Before going further, it may be well to say that this 
article has nothing in its character even tangent to the 
occult or mystic. If I should show that certain num- 
bers have power in the living body I shall be wandering 
from the highway of the physical no more greatly than 
the chemist when he writes down the invariable molecular 
weight of iron. 

One of the most important conditions of life-tenure is 
time. It would be needless to labour the point how it 
indicates the expectancy of parturition, teething, puberty, 
adult vigour, and senility. 

But there is not only a time astronomical; there is, I 
submit, one essentially biological. The calculations of 
the astronomer by which he marks the years agree with 
biology only in regard to the day unit. In human biology 
the very first temporal quantity is that of gestation — 280 
days. The menses occur every twenty-eighth day. Seven 
is a factor in both numbers. Seven is also found in the 
ratio of the usual number of menstrual days to 280, which 
is forty. Medical men of good repute have stated that 
with most women the menses occur during the first seven 
days of the moon's age. 

The salivary glands become physiologically active about 
280 days after birth. The cutting of the milk teeth cor- 
responds in periods of days to multiples of seven. The 
thymus gland begins to atrophy at about the seventh period 
of 280 days from birth, corresponding to the sixth astro- 
nomical year of life. Thirty-five such periods, that is, five 
multiples of seven, equal the first twenty-six common 
years, whose completion synchronises with that of bodily 
development. In eastern countries — the cradle home of 



232 Some Suggestions in Micro-Biometrics. 

humanity — puberty is attained in about fourteen such bio- 
logical, or ten common years. One could multiply data, 
but I think sufficient have been adduced to warrant the 
conclusions that we have a true biological year of 280 days, 
that its multiples and dividends correspond with physio- 
logical stages, and that in all such numbers we have the 
factor seven. 

Equally true is it that seven is to be found in the cardiac- 
respiratory ratio. The normal pulse is usually given as 
72, and the respiratory frequency as 18; but a moment's 
thought will show that there are more nearly 70 respira- 
tions to 280 pulse-beats ; the ratio being that of ten sevens 
to forty sevens. 

The total capacity of the capillaries is 700 times that of 
the aorta, or seven aortic capacities, multiplied by one 

hundred. 

The ratio between the number of complete blood cir- 
culations to pulse-beats works out as 7 to 126. One com- 
plete circulation occupies 15 seconds. The number of 
pulse-beats corresponding to this time is 18 ; therefore , 
7 circulations agree with 126 pulse-beats. 

Any attempt at an exhaustive research into the ratios 
of histological units must take account of mass ; but for 
the purpose I have immediately in view it will be better 
to deal with the more generally known linear measurement. 

Before going further we may ask how any number-unit 
would in the nature of things be affected by the molecular 
constitution of the body? It must be held in mind that 
our molecular ultimates are so small that aggregates of 
six, eight, or even nine would, when multiplied by bil- 
lions, give aggregates of the coarse or visible kind scarcely, 
if at all, distinguishable from seven. Moreover, we may 
be dealing with molecular aggregates in each of which 
there are molecules of differing numerical value. From 
either would arise what I may term " fluctuation." The 
gross values would circulate round a central figure, some- 
times only exactly agreeing with it. 

As a fact, that is just wh^'t does obtain, 



By Edwin WootoN. ^33 

Hence, in dealing with seven as a tentative unit it will 
be helpful if we represent it by some such symbol as 
( + 7-). 

I suggest that the starting concrete point of our calcula- 
tions be the germinal nucleolus. It has not an unvarying 
size, but in a well matured ovum it has a fairly constant 
ratio to the nucleus. Histologists usually assign seven 
mikrons to the diameter of the nucleolus, and fifty to that 
of the nucleus. In accordance with the principle of fluc- 
tuation we will write the proportions as 1 to ( + 7 - ). 

In the course of our work we shall have to do with struc- 
tures smaller than the nucleolus, and we must make pro- 
vision for the not improbable contingency of our becoming 
familiar with structures more minute than have yet been 
distinguished. It will, therefore, be convenient to intro- 
duce an abstract unit of measurement, and we will call it 
a bion. Recognising that our only tentative guide to ratio 
is the number seven, we will make one bion the seventh 
part of a mikron. 

Now, keeping to the nucleolus as our concrete unit, and 
always giving our factor seven the value ( + 7 - ) , we could 
estimate the proportion between the nucleolus and other 
structural elements, and by this means we might arrive at 
something approximating verity as to the laws governing 
the multiples or dividends of seven in body-building ; but 
it would necessitate a radical revision of every biological 
measurement. In effect, it w^ould replace the metric 
system by another. As a matter of convenience it may be 
well to avoid this. Some revision will be essential, but by 
still giving a place to the millimetre we shall at the outset 
find matters run more smoothly. 

That the diameter of the nucleolus is seven mikrons is 
a most happy, fortuitous agreement with the principle on 
which we are working, for we have = nucleolus, 7x7, 
nucleus 7x7x7. 

Physiologists give the weight of body blood relative 
to body weight as near the thirteenth ; that will agree 
with our fluctuating value, being ( + 7- )-j-2. They give 



234 Some Suggesiiuns in Micro-^iometncs. 

the weight percentage of ha3moglobin in the blood as about 
a thirteenth ; that also will agree with ( + 7 - ). The per- 
centage of iron in hcrnioglobin is (roughly) .4, that is one 
part in two hundred and fifty, which agrees with 
( + 7-)x37. 

Muscle- weight relative to body-weight is 42 per cent., 
or three-sevenths. The body contains about 64 per cent, 
of water, that is 4^-sevenths ; and 21 per cent, of protein 
is in muscle, equalling ( + 7 - ) x 1\. Muscle contains 
somewhere round 75 per cent, of water, or five-sevenths. 

In all these computations it must be kept in mind that 
the analyses vary. They all, however, show the number 
seven constantly as a ratio or prime factor in a ratio. 

We may take the nitrogen output of the skin relative to 
the total output as 1 to 21, or as 1 to ( + 7 - ) x 3. 

It has been calculated that there are approximately three 
hundred and fifty-five millions of alveoli in the human 
lungs, which number, allowing for errors, is a multiple of 
seven. 

The primordial ovarian follicles of the newly-born child 
are seventy thousand in number. 

Anyone even superficially acquainted with the human 
body could answer my argument by the production of 
seemingly controverting facts. He could say, for in- 
stance : — Here are three structural elements having the 
respective diameters eleven, twelve, and seventeen 
mikrons. Where is your seven factor? 

My answer would be that if we honestly find the seven 
factor does obtain in a sufficiently large number of activi- 
ties and structures to warrant any attention at all we shall 
be acting in the true spirit of science if we seek for an 
explanation of such apparent irreconcilables rather than 
if we regard them as things insuperable. In a case such 
as that just advanced we have but to introduce the multiple 
that we have already found to be operative in other ratios, 
and we shall see the possibility of 77, 84, and 119 being 
the ratios obtaining here. Expressed in terms of seven, 
they would be=: ( + 7 - ) x 11, (-f-7 - ) x 12, (-^ 7 - ) x 17. 



By Edwin Wooton. 235 

Here are a few other constants : — The sweat glands of 
the surface have a diameter of coil ranging from .7 to .35 
mm. In the axilla they are much larger, but in each case 
their size is a multiple of ( + 7 - ). 

Let me advise the captious reader not to exclaim tliat J 
have already stated such measurements to be in character, 
as in effect, factitious. They are such ; it is in the relation 
of the measurements to other measurements that the ratios 
of the concrete things are to be found. 

Sound is an interpretation of vibrations, and the seven 
notes of the scale are physiological facts. The cells of the 
anterior horn of the spinal cord = 135 mikrons in diameter. 
The minute fusiform cells of the retina have a diameter of 
10 mikrons. The ratio, as 10 to 13^, may be expressed as 
10 to ( + 7 - ) X 2. The radial width of the basilar mem- 
brane, measured from the entrance of the nerve fibres to 
the spiral ligament, is = 3 mm. x (+ 7 -) in the basal 
whorl, 5 mm. x ( + 7 - ) in the middle whorl, and 

5 mm. X ( -f 7 - ) in the topmost whorl. 

The nupiber of inner hair cells has been estimated at 
3,500, that is 500 x ( + 7-). The outer rods of Corti are 
800 X ( + 7 - ), and the inner rods are 550 x ( + 7 - ). 

It is quite in harmony with the facts adduced that while 
the ratios between (1) the length of the trunk, and the 
limbs, and (2) the weights of internal organs, and (3) the 
measurements of such organs contain the factor ( + 7-), 
we often see it absent in the girth measurements of limbs 
and trunk and neck. It is to be remembered that these 
last are often expressive of purely factitious or fortuitous 
conditions. A course of physical culture, over-feeding, or 
insufficiency of diet will totally obscure any original ratios. 
Thus, although the female trachea in proportion to that 
of the male is in its transverse diameter as 18 to 21, or 

6 to 7, the neck girth measurements and their ratios are 
as variable as luck itself. 

If, pursuing his inquiries carefully through a series as 
lengthy as he may deem needful, the physiologist shall find 
the obtainment of the seven or any other ratio to be a law 
of the organism, he will not be making a hazardous guess 



236 Some Suggestions in Micro-Biometrics. 

in believing that probability points to it as a factor in 
metabolism itself. 

Here are a few more suggestive data : — 

As one respiration occupies 3.33 seconds, and one pulse 
beat occupies .833 seconds, the ratio of respiration to 
pulse beat is as one to four, or (+ 7 - ) to 28. The ratio 
of the auricular systole to the ventricular is 1 to (+ 7 - ). 
As nerve force travelling at 35 metres a second passes 
through the body of a man of six feet in .19 seconds, and 
there are 12 muscular contractions per second, the ratio 
in point of work is .631 of a contraction to one nerve 
current unit, and in point of time as .083 second to .19 
second. The ratio of the cardiac systole to nuiscular 
contraction is as 9 to 6, or as one nuiscular contraction to 
.15 systole. (Compare with .15 of circulation in one 
second.) 

As a man of about twelve stones in weight has a right 
ventricular capacity that may be set down as three fluid 
ounces, the entire blood of his body — which will be close 
upon 208 ounces — must • pass through the ventricle in 
69.9 beats. The smaller the body, the less the capacity 
of the ventricle, and the less the blood quantity. The 
ratio will be found to keep its integrity. Hence, seventy 
beats may be held to constitute a true physiological work 
unit. 

Taking the biological year as 280 days, and the astro- 
nomical as 365 days, we have fff = .767. 

Taking the pulse as 72 per minute, and the minute as 
60 seconds, we have |4 = .833. 

The difference between the ratios is only .066. Allow- 
ing for physiological fluctuations, the fractions are iden- 
tical. We may therefore say that as the pulse is to the 
minute, so is the biological year to the astronomical. 

The Imman body presents no single instance of a 
mathematically exact and invariable constant. In 
periodicity, chemical constitution, measurement, and 
weight we see only limited variants. 

Whether we take an average, a dominating — that is 
a " usual " (jiiantity — or state the variations we shall 



By Edwl\ Wooto.V. 237 

find three factors most frequently operative : — 3, 5, and 
7. Seven could be expressed by ( + 3 - ) x -J. 

In some cases five appears to fit more exactly than 
seven. It may be that each of these three is a unit 
number. Only a long and careful series of computations 
can determine the point. I am not holding a brief for 
Seven, save as expressive of the truth that nniltiple pro- 
gression obtains. That truth is placed beyond all ques- 
tioning by periodicity. The ratios are too marked, and 
the functions too vital for the former to have no signifi- 
cance. And it should be kept in mind that every ob- 
servable function is a summation. Hence all relativi- 
ties of adult life might be expected to obtain from the 
very incidence of the embryonic, as do the more obvious 
characters that make up physical personality. 

As yet we do not know what lies between the chemical 
molecule and the cell ; but the obtainment of any ratio 
number points to it as ex])ressiug a unit of progression ; 
and the inquirer will not wander far from the right path 
if he grasps it as a clue that shall guide him in investigat- 
ing the constitution of the cell itself. For, as the greater 
is but the lesser greatly multiplied, so must any numerical 
factor found as a " constant " in the greater be operative 
in the genesis of the bodv's structural units. 



I 



PERISCOPE. 

THE DOG AS A CARRIER OF DISEASE. 

The United States of America Department of Agriculture has 
issued a valuable paper {Pacific Medical Journal, Vol. LIX., 
No. 2) on the dog as a carrier of disease. Of the diseases 
carried to stock by dogs, the foot and mouth disease is prob- 
ably of the greatest interest at this time. The virus of the 
disease is carried on the feet of the animal from the affected 
farm to other farms, and thus the disease is spread to neigh- 
bouring herds. In Bulletin 20 of the Agricultural Dep irtment 
it is pointed out that dogs convey rabies, hydatids, ringworm, 
favus, tapeworm, roundworm, and occasionally — by fleas 
and ticks — bubonic plague or the deadly " spotted fever " to 
human beings. 



PART 11. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Principles of Diagnosis and Treatment in Heart Affections. 
By Sir James Macken^zie, M.D.. F.R.S., F.R.C.P., 
LL.D., Ab. and Ed., F.R. C.P.I. (Hon.), Physician to 
the London Hospital (in charge of the Cardiac Depart- 
ment), Physician to the Victoria Hospital, Burnley. 
London : Henry Frowde and Hodder & Stoughton. Ox- 
ford Medical Publications. 1916. Demy 8vo. Pp. 
viii. + 264. 

There is a delightful freshness about this work from a 
master-hand. Iconoclastic views crop up on nearly every 
page, and with them, or with most of them, we frankly 
confess that we are in close accord. 

As the reader gathers from the title page, the author 
is in charge of the Cardiac Department of the London 
Hospital. His high reputation as an authority on heart 
affections has naturally attracted to that hospital large 
numbers of post-graduate students and workers. Two 
years ago Sir James Mackenzie prepared a course of 
lectures for the post-graduate class. The outbreak of the 
(Treat War prevented the delivery of that course, but 
fortunately for present and future members of the Medical 
I'rofession these most interesting and instructive 
lectures have now been published by the Joint Committee 
of Henry Frowde and Hodder & Stoughton as one of the 
" Oxford Medical Publications." In a well-printed volume 
the subject-matter is divided into chapters instead of 
lectures, while the colloquial form of expression has been 
retained by the author. 

The phrase ' ' Heart Failure ' ' is hackneyed — it is in 
every-day use on the lips of the public, and we are sorry 
to say is often used by medical practitioners as a cloak 
for ignorance, falling into the category of such vague 
terms as " influenza," " influenzal cold," " below par," 
" run down," " bilious attack," " gastritis." " sick head- 
ache," and others of that class. 



MACKJtiNZiE — Treatment in Heart Afjcctio\is. '239 

And yet that very phrase "Heart Failure" is choaen by 
Sir James Mackenzie as the pivot on which this work 
turns. " As the main question in every examination of 
the heart," he writes in the Preface, " is concerned with . 
heart failure — whether it is present or foreshadowed — one 
of the objects I have in publishing this book is to present 
the essential matters connected with heart failure in such 
a manner that the general practitioner can appreciate 
them and apply them in his practice." 

Another object which the author has had in view — we 
again quote from his Preface — " is to present this subject 
in such a form as to lead to a better conception of what 
Clinical Medicine means, and how clinical investigations 
should be carried out, and, if possible, to stimulate re- 
search on lines which are essential to advance, but which 
have been wholly neglected." 

What those lines are the first " Lecture," or Chapter 
1., makes clear. Its heading is " Medical Kesearch." 

Addressing his "class," or his readers, Sir James 
observes : "The life of a general practitioner is not con- 
sidered one that can help much in the advance of Medicine ; 
it is, indeed, regarded so lightly that no steps are ever 
taken to train one who intends to become a general prac- 
titioner in any branch that would enable him to under- 
take research work. You know well that if a man aspires 
to research work it is to the laboratories or to the hospital 
wards he is sent. As a result of my experience, I take 
a very different view, and assert with confidence that 
Medicine will make but halting progress while whole 
fields essential to the progress of Medicine will remain 
unexplored, until the general practitioner takes his place 
as an investigator. The reason for this is that he has 
opportunities which no other worker possesses — opportu- 
nities which are necessary to the solution of problems 
essential to the advance of Medicine " (Pages 1 and 2). 

His line of argument is as follows : The investigation 
of the early stages of disease has not yet been seriously 
undertaken. Clinical research at the present day deals 
with disease at an advanced stage. To acquire a 
knowledge of the life-history of chronic disease it is neces- 



240 heviews and Bihliographical Noticed. 

sary to be able to follow individual cases from the start 
to the finish. The knowledge of the progress of disease 
reveals the meaning of abnormal signs and constitutes the 
basis for an intelligent prognosis. Investigation of pro- 
gnosis can be carried out only by those who have the 
opportunity of watching individuals during the whole 
course of the disease. This is where the general prac- 
titioner and his work come in. The opportunity for 
investigation in hospitals is too restricted : the general 
practitioner is the only investigator who has the real 
opportunity. In Clinical Medicine, methods of research 
must be adopted that are peculiar to this branch of 
Science. There is necessity for study of an individual 
patient's sensations : this can be carried out only by the 
medical practitioner who has watched such a patient 
through, it may be, many years. 

It may seem strange that such views .should be held 
by one who has done so much to throw light ujwn the 
mechanism of the heart in health and disease through 
scientific research by means of instruments of precision 
such as the sphygmograph, the electro-cardiograph, the 
Eiva Rocci sphygmomanometer, and so on. But that is 
just the j)oint which the author makes — ^in his own words 
([jage 85) : " The means of investigation which we }x>ssess 
in ourselves, without the use of mechanical devices, have 
not yet even been begun to be employed on a scientific 
basis." He adds : '' xVs yet we scarcely perceive the 
limitations of laboratory methods." 

Sir James is very hard on the British Pharviacopma, 
1911. He writes (page 34) : "Take the otficial pharma- 
copoeia, and inquire into the grounds on which the various 
drugs have gained admission to its pages. You will find 
Ihat the vast bulk of these drugs has never been subjected 
to any accurate observation, and that many have gained 
admittance because the ix)pular belief attributed to them 
some supposed effect — evidence that w(nild equally have 
justified the inclusion in the pharmacopoeia of the King's 
touch, amulets, and invocations. Even the few drugs that 
are of value have never been observed with that precision 
which would enable the student to understand how to 



UACKEmm— Treatment in Heart Affections. 241 

make the best use of them. I trust it will not be long 
before the most recent of pharmacopoeias will be regarded 
as no more authoritative in therapeutics than would a 
medieval work on alchemy be regarded as authoritative 
as a text-book of modern chemistry." This is severe— 
but all the same, in one of the chapters on " Treatment " 
(Chapter XXVI.), when describing the great value of 
digitahs in certain forms of "heart failure," Sir James 
does not hesitate to say (page 236) : " Any preparation of 
the drug can be used, for no advantage appears to attend 
the use of special forms. I have never found the B. P. 
tincture fail me, and it is this form which I have used 
most frequently, because it is the cheapest, and therefore 
is within reach of the poorest." Our author is not 
very loyal to the British Pharamacopceia , for he adopts in 
his text the terms "nitroglycerin" and "veronal" in 
preference to " trinitrin " and " barbatone " (pages 244 
and 245). By the way, the latter can hardly be called 
one of the " milder hypnotics." 

While we agree with Sir James Mackenzie in holding 
that the beginnings of disease should be carefully and 
systematically watched, we cannot help wondering how 
the general practitioner can avail himself of the opportu- 
nities for such a study. 

In Chapter IT. "Heart Failure" is defined as " that 
condition in which the heart is unable. to maintain an 
efficient circulation during the efforts necessary for the 
daily life of the individual." "The study of heart 
failure," the author goes on to state, " practically resolves 
itself into an inquiry into the circumstances which have 
impaired the functional efficiency of the heart muscle." 
Throughout this interesting and suggestive w^ork, the 
author puts the patient, and his or her sensations, first; 
physical examination next ; and instrumental and labora- 
tory aids last. 

In Chapter IV. we are told that symptoms are produced 
in three different ways, according as they modify the 
structure of an organ, or its functions, or call into play its 
protective mechanism. In subsequent chapters these 



242 Reviews and Bibliographical Notices. 

three different kinds of symptoms are described under 
various headings. The structural are described in chap- 
ters which deal with increased size of the heart, murmurs, 
and abnormal rhythm. The functional are described under 
such headings as " breathlessness " (Chapter V,), " faint- 
ing," (Chapter VI.), "dropsy" and the like (Chapter 
VII.); the protective under " angina pectoris," to which 
Chapter VIII. is devoted. This is a novel view to take of 
the last-named agonising symptom, but we thoroughly 
agree with it. Among the provocative causes of an attack 
mentioned at page 80, we note two omissions — hill-climb- 
ing and facing a high wind. 

Sir James accepts the view that the most frequent 
physical conditions provoking angina pectoris are the de- 
generative atheromatous changes in the coronary artery 
which accompanies advancing years. He instances an 
analogous effect following an atheromatous condition of the 
arteries in the legs. Many elderly people, he tells us, 
who can walk for miles at a slow rate are compelled to 
stop if they attempt to hurry, or run, by the intense aching 
which occurs in their feet and legs (page 73). 

In Chapter VTI., on "Objective Signs of Heart Failure," 
we are inclined to call in question the statement that 
" oedema about the ankles is common in many practically 
healthy people towards the end of the day." Nor can we 
approve the author's practice in cases of heart failure in 
typhoid fever of getting the patient to sit up before auscul- 
tating the lungs. At the same time we agree with his 
opinion that, when crepitations are heard in such a case, 
this physical sign is due to the failure of the right ventricle 
to send the blood efficiently through the lungs, and that 
lying in bed compressed the ribs and interfered with free 
breathing, while sitting up, on the other hand, freed the 
ribs, the resulting deeper breathing assisting the heart to 
send the blood through the lungs. 

In Chapter X. the author points out that functional in- 
efficiency of the heart is indicated in one case by pain 
(angina pectoris), in another by breathlessness on exertion, 
or, in advanced failure, at rest. The production of pain in 
visceral disease requires a stimulus of a certain elusive 
kind, which — he tliinks — we are ycf far from interpreting. 



Mackenzie — Treatment in Heart Affections. 243 

" The Examination of the Patient " forms the subject 
of Chapter XIT. Physicians and medical students ahke 
may read it with advantage. 

Physical Examination begins in Chapter XIV., and 
occupies it and fhe following five chapters. The topic is 
discussed from the clinical side. In Chapter XVI., on 
" Affections of the Myocardium," we come across a de- 
lightfully satirical passage about " compensation." " The 
use of this term," writes the author, " is characteristic of 
much that is vague and unscientific in medicine. Even 
those who use it never explain what they mean ! " "I 
have even known a distinguished professor of medicine 
rejoice the heart of a man with aortic disease, who could 
not walk one hundred yards without being pulled up by 
pain, by telling him that his outlook was good as there 
was no dropsy, and, therefore, compensation was good ! 
Yet this man died shortly after from heart failure, and 
no dropsy ever appeared " (page 135). 

A novel light is thrown on irregular heart action in 
Chapter XVII., in which Sir James classifies the cases 
into youthful and adult types. In the former all the 
chambers of the heart participate in the irregularity ; in 
the latter, the ventricle contracts prematurely while the 
auricle maintains its rhythm, or both auricle and ventricle 
contract prematurely — the irregularity which is now 
called the ventricular and auricular extra-systole. The 
youthful type is to be regarded as physiological, for it is 
present in perfectly healthy hearts. The author goes so 
far as to maintain that its presence after a febrile illness 
may be taken as an indication that the heart has escaped 
infection. His reasoning is that the young heart shows 
this irregularity because the muscle is fresh and healthy 
and susceptible to the slightest stimulation. The disap- 
pearance of the irregularity, with increase of rate by fever, 
showed that the weak stimulus from the vagus was in- 
effective during the time that febrile irritation was present ; 
but the vagus stimulation re-asserted its sway when the 
irritation was removed. 

The subjects of auricular fibrillation and auricular flutter 



244 Reviewf! and BihUographical Notices. 

are considered in Chapters XVIII. and XIX. These are 
subjects which the author has made peculiarly his own. 
Auricular fibrillation he regards as a symptom of some 
myocardial change (page 167). If the ventricles pass into 
fibrillation death is instantaneous. 

In the chapter on Blood Pressure (XXII.), the author 
gives loose rein to his iconoclastic steed. He is particu- 
larly severe on "the spa physician." " A short time 
since," he tells us, " I was consulted by a man on his way 
to a watering-place. His blood-pressure was 190 mm. 
Hg. He returned two months later, very cheerful be- 
cause his spa physician had reduced his blood-pressure to 
130 mm. Hg. I again took the blood-pressure and found 
it 195. I did not undeceive him as the delusion made him 
very happy." He goes on: "It had been a matter of 
wonder to me to see the extraordinary resourcefulness of 
those who treat blood-pressure and the numerous theories 
that guide them. The drugs that have been employed 
are legion in number, diets of the most contrary descrip- 
tions — all-flesh diet, vegetarian diet, purin-free diet, and 
various other modifications ; baths and waters and exercises 
of all kinds ; high frequency current and other electrical 
devices. Notwithstanding this the blood-pressure has 
remained high " (page 204). 

The author believes that when we have sufficient know- 
ledge of the blood-pressure we shall find it of considerable 
help in our work, but there is no prospect of our acquiring 
that knowledge in the near future. The observers who 
alone are capable of undertaking this quest, according to 
him, are young practitioners in general practice, because 
they have the two great essentials — the opportunity for 
watching individuals for many years and the prospect of 
living long enough to complete their observations ! 

One of the most amusing passages in the book is the 
onslaught Sir James Mackenzie makes on the claims 
which have been advanced on behalf of the " magical 
effect " of the carbonic acid baths of Nauhcim. Here is 
the concluding sentence of his philippic: — "The repu- 
tation of Nauheim baths and of the artificial imitations of 



]\rACKRNZlE — Trratrncrit iv Heart Affections. 245 

them depends, it becomes quite evident, more on brazen 
advertisements, financial interests, and the slavish tributes 
of other spas, than on an intelligent appreciation and ap- 
plication of the principles of treatment " (page 230). 

This work gives much food for thought. The author 
is a doughty champion of chloroform as an anaesthetic, and 
he has given it successfully in cases with very marked 
heart disease (complete heart-block, auricular fibrillation, 
and all forms of cardiac disease). The cause of sudden 
death was stated long ago by Mac William to be, in all 
probability, fibrillation of the ventricles. MacWilliam 
and Levy have since then, as the result of experiment, 
found that fibrillation of the ventricles is also the cause of 
sudden death under chloroform anaesthesia, and the latter 
observer has stated that sudden death is more likely to 
occur with insufficient anaesthesia than with full 
ancesthesia. In these views Sir James Mackenzie con- 
curs. Lastly, there is a shrewd remark on page 228 that 
" to every case of heart affection there is a mental side." 
The author is discussing the question of exercise. 
"Mechanical exercises," he writes, "tend to remind the 
patient that he is an invalid, whereas a game, or an exercise 
in the fresh air with an object beyond the consideration of 
health, has a beneficial mental effect." He enunciates a 
principle of the highest importance when he states that 
a patient should take that amount of exercise which gives 
pleasure and does not give rise to sensations of distress 
or discomfort. 

The book is well written in clear and simple English. 
The word "only" — thdit bete noir of many writers — is 
repeatedly misplaced, and " still " shares its hapless fate 
in a sentence at page 231. As to the " setting " of the 
volume there is little to criticise, but we cannot approve 
the Americanism of splitting at the end of lines certain 
words according as the letters suit the space, and not 
according to syllables or with reference to their derivation : 
" prog-nosis," " diag-nosis," " symp-toms," "regur- 
gitation," are neither elegant nor scholarlv. 

J. W. M. 
s 



246 Reviews ayid Bihliographical Notices. 

RECENT WORKS ON SURGERY. 

1. Manual of Operative Surgery. By John Fairbairn 
BiNNiE, A.M., CM. (Aberdeen), F.A.C.S. ; Surgeon to 
the Christian Church, the German and the General 
Hospitals, Kansas City, Mo. ; Fellow of the American 
Surgical ^Association ; Membre de la Societe Inter- 
nationale de Chirurgie, and Member of the Western 
Surgical Association. Seventh Edition, revised and 
enlarged, with 1,597 Illustrations, a number of which 
are printed in colours. London : H. K. Lewis & Co., 
Ltd. 1916. Pp. XV + 1363. 

2. Mafiual of Surgery. By Alexis Thomson, F.E.C.S. 
Ed.; Professor of Surgery, University of Edinburgh; 
Surgeon, Edinburgh Royal Infirmary; and Alexander 
Miles, F.R. C.S.Ed., Surgeon, Edinburgh Royal In- 
firmary. Fifth Edition, revised and enlarged, with 289 
Illustrations. Edinburgh, Glasgow, and London : 
Henry Frowde and Hodder & Stoughton, 1915. Volume 
I., pp. xix + 801. Volume II., pp. xvi + 948. 

3. Cancer of the Stomach : A Clinical Study of 921 Opera- 
tively and Pathologically Demonstrated Cases. By 
Frank Smithies, M.D. ; Gastro-Enterologist to Augus- 
tana Hospital , Chicago ; formerly Gastro-Enterologist to 
the Mayo Clinic, Rochester, Minn. ; formerly Instructor 
in Internal Medicine and Demonstrator of Clinical 
Medicine in the University of Michigan, Ann Arbor; 
Fellow of the American Gastro-Enterological Associa- 
tion, &c. With a chapter on the Surgical Treatment of 
Gastric Cancer, by Albert J. Ochsner, M.D., 
LL.D., F.R.C.S. ; Professor of Clinical Surgery in the 
School of Medicine of the University of Illinois; 
Surgeon-in-Chief to Augustana Hospital, Chicago; Con- 
sulting Surgeon to St. Mary's Hospital, Chicago. 
Illustrated. Pp. 522. 

L Mr. Binnik's Manual of Operative Surgery is now 
so well known as to merely require notice of the appear- 
ance of a new edition. 



Recent Works on Surgery. 247 

The main feature of the edition before us is the addition 
of an Appendix on War Surgery, by Walter S. Sutton, 
M.D., F.A.C.S. In it will be found many radical varia- 
tions in the application of the general principles of surgical 
treatment, which, of course, are identical in civil and mili- 
tary surgery. 

In this appendix the author considers the character of 
the surgery wdiich ought to be carried out : 1st, at the 
fighting hne; 2nd, in transport; 3rd, at the first line base 
hospital — in other words, at what we know as the Casualty 
Clearing Station (C. C. S.^ ; 4th, at the base hospital in the 
rear. 

Infection of wounds, we know, is the great trouble that 
has to be combated. The infection has its origin in the 
patient's immediate surroundings or on the surface of the 
body. The author of this section says : ' ' The great mass 
of infection is traceable to dirty bodies and filthy clothing, 
and stands as a reproach to present-day military surgery. 
. Gas infection, particularly — almost as deadly as 
tetanus itself — should prove preventable by efficient ar- 
rangements for personal cleanliness." How this is to be 
prevented we are not told. Efficient arrangements for 
personal cleanliness cannot well be provided in the 
trenches, which must very often be very hastily dug in the 
fighting line, and to us, who have seen the actual state of 
things in the trenches and in those coming therefrom, it 
seems an utter impossibility to avoid or prevent infection 
of any wounds inflicted upon a soldier in the trenches. 
The only way by which the mortality and dangers from 
such unavoidable infection can be diminished is by freely 
opening up all wounds, removing all foreign bodies, and 
providing for the freest possible drainage at the earliest 
possible moment after the wound has been inflicted. 

In this section an unnecessary amount of space is taken 
up by a description of the localisatiofe of foreign bodies. 
The work has been well revised, and brought up-to-date in 
every respect. The illustrations, as in former editions, are 
numerous and well-chosen. 



248 Reviews and Bibliographical Notices. 

2. It is unnecessary to do more than draw attention to 
the appearance of a new edition of Mr. Thomson's practical 
Manual of Surgery. We have always been of opinion, 
from the time the first edition of this work appeared, 
that it was one of the soundest and most practical 
manuals on surgery the student could desire, and, as 
time passes by and fresh editions appear, we have seen 
no reason to vary that original opinion. The present 
edition has been thoroughly revised, and many sections 
have been re- written in order to bring them into line with 
recent advances in pathology and treatment. Controversial 
matters are eliminated, and only those which have been 
firmly established will be found incorporated in the 
present edition. 

The procedure adopted in former issues has been 
followed in this edition, viz. : — Volume T. is devoted to 
general surgery, and Volume II. to a consideration of 
regional surgery. The description of operations has been 
rightly eliminated, and a third volume, we understand, 
has been issued dealing exclusively with operative surgery. 

3. This volume is really a treatise, and a most valuable one, 
upon a subject of vast importance to physician and surgeon 
alike. The great value of the book lies in the fact that it 
is the outcome of an extensive practical personal experience. 
One exceedingly iifteresting chapter is No. IX., on Gastric 
Cancer in the Young. In this series of cases there were 
12 females and 8 males. The youngest was 18 years, and 
the oldest just past 30 years. The average age of the 
series was 27.2 years. In two instances (12 per cent.) 
there was a family history of cancer. The chapter on the 
Surgical Treatment of Cancer of the Stomach consists of 
54 pages, and, as one would expect from the standing of 
its author, it is quite good, and a detailed dietary is out- 
lined for patients to follow subsequent to recovery. 

The book is one which will well repay l)oth physicians 
and surgeons who study it carefully. 

W. T, 



PABT III. 
MEDICAL MISCELLANY. 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics. 

For four weeks ending Saturday, September 9, 1916. 

IRELAND, 

The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institu- 
tions from without the respective districts — registered in 
the week ended Saturday, September 9, 1916, in the Dublin 
Registration Area and the eighteen principal provincial Urban 
Districts of Ireland, was 13.7 per 1,000 of the aggregate 
population, which for the j)urposes of these returns is esti- 
mated at 1,122,268. The deaths from all causes registered 
in the week ended Saturday, September 9, and during the 
period of four weeks ended on that date, respectively, were 
equal to the following annual rates per 1,000 of the 
population : — 

Nineteen Town Districts, 13.7 and 14.7 ; Dubhn Registra- 
tion Area, 14.8 and 16.2 ; Dubhn City, 15.8 and 17.9 ; BeKast, 
13.4 and 14.7 ; Cork, 13.6 and 12.6 ; Londonderry, 7.8 and 
16.3 ; Limerick, 16.2 and 15.2 ; and Waterford, 11.4 and 11.4. 

The deaths from certain epidemic diseases — namely, enteric 
fever, typhus, small-pox, measles, scarlet fever, whooping- 
cough, diphtheria, dysentery, and diarrhoeal diseases — regis- 
tered in the 19 town districts during the week ended Saturday, 
September 9, were equal to an annual rate of 2.7 per 1,000. 
Among the 100 deaths from all causes in BeKast were 2 from 
enteric fever, 1 from whooping-cough, 1 from measles, 1 from 
scarlet fever, and 18 from diarrhoeal diseases. The deaths of 
2 children, both under 2 years of age, from '' diarrhoea and 
enteritis," are included in 6 deaths from all causes registered 
in Londonderry. One death from measles and 1 death from 
whooping-cough are included among 6 deaths recorded in 
Waterford . 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock 
and Kingstown. The population of the area is 397,000. 

In the DubUn Registration Area the births registered during 



250 Sanitary and Meteorological Notes. 

the week ended September 9 amounted to 219 — 107 boys and 
112 girls, and the deaths to 129 — 66 males and 63 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 16) 
of persons admitted into public institutions from localities 
outside the Area, represent an annual rate of mortahty of 
14.8 per 1,000 of the population. During the thirty-six 
weeks ended with Saturday, September 9, the death-rate 
averaged 20.2, and was 1.5 below the mean rate for the cor- 
responding portions of the 10 years 1906-15. The rate for all 
deaths registered during the thirty-six weeks was 21.8, and 
for the corresponding period of the preceding 10 ye-ATs it had 
been 22.9. 

The 113 deaths appertaining to the Area included 1 from 
measles, 1 from dysentery, 1 from whooping-cough, 26 of 
children under 2 years from diarrhoea and enteritis. In the 
three preceding weeks deaths from measles had numbered 

I, 2, and 1 ; deaths from whooping-cough, 1,1, and 2 ; and 
deaths from diarrhoea and enteritis of children under 2 years, 

II, 17, and 31. 

Tuberculosis caused 18 deaths, as against 25, 16, and 20, 
respectively, iu the three weeks preceding. Of the 18 deaths 
ascribed to tuberculosis, 16 were referred to puhnonary tuber- 
culosis, 1 to tuberculosis of joints, and 1 to disseminated 
tuberculosis. 

Thirteen deaths were caused by cancer, 4 by pneumonia 
(1 by broncho-pneumonia and 3 by pneumonia, type not 
distinguished), 9 by organic diseases of the heart, and 1 by 
bronchitis. 

Among deaths of infants under one year old, 1 was ascribed 
to congenital debility, 3 to prematurity, and 1 to convulsions. 

Four deaths were due to violence. 

Forty of the deaths registered during the week appertaining 
to the Area were of children under 5 years of age, 29 being 
infants under one year, of whom 5 were under one month old. 

Of the 113 deaths recorded, 36 occurred in hospitals and 
other public institutions. 

STATK OF INFECTIOUS DISEASE. 
The foHowing returns of the number of cases of Infectious 
Diseases notified under the "' Infectious Diseases Notifica- 



Sajiitanj and Meteorological Notes. 



251 



tion Act, 1889," and the " Tuberculosis Prevention (Ireland) 
Act, 1908," have been furnished by the respective sanitary 
authorities : — - 

Table I. — Showing the Number of Cases of Infectious Diseases notified in the 
Dublin Registration Area — (viz., the City of DubUn and the Urban Districts of 
Rath mines and Rath gar, Pembroke, Blackrock and Kingstown), and in the Cities 
of Belfast. Cork, Londonderry, Limerick, and Waterford, during the week ended 
September 9, 1916, and each of the preceding three weeks. 
A dash ( — ) denotes that the disease in question is not notifiable in the District, 



CITIKS A?tl) 

UiiBAN nismiCTS 


Week 
ending 


1 


B 
fl 

¥ 


> 


i 
"5. 


<D 

> 

c 
a 

IB 

K 


(5 


c ^ 
'Sue 

t = 

>. 

0-, 


> 

I's. 


a. 

E- 


«>■ 
2 

c 
a. 
u 
«> 

3 
ft 


a 
o 

it 
c 

'E. 
o 
o 


13 

CD Q 


CS Oi 

3 


c 

.2 
5 


55 



11 

11 

3 


13 
o 


City «f Dnl.liii < 

RKtIiiniiiaH ami ( 
Rathgar 1 
Urban | 
Didtrioi (, 

Pembroke | 
Urban < 
District 

Blackrock 1 
Url)an { 
l>iM(,rict 1 

Kin(;!itowM 1 
Urban \ 
DiHtrict 

Clly of Kelfant | 

City of Cork } 

City of London- 1 
derry j 

City of Limerick • 
CityofWaterfordj 


Aug. 13 

Aug. 26 
Sept. 2 
Sept. y 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. y 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. y 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. 9 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. y 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. 9 

Aug. 19 
Aug. 26 
Sept. 2 
Sept. 9 

Aug. 19 
Aug 26 
Sept. 2 
Sept. 9 

Aug. 19 

Auff 26 
Sept. 2 
Sept. 9 

Aug. 19 
Aug. 29 
Sept. 2 
Sept. 9 


2 


- 


4 
7 
10 

1 
1 
1 

i 

1 

12 
12 
10 
12 

? 

2 

1 

3 
l' 

2 

1 

1 


1 
1 

i 




4 
1 
3 

1 

1 

I 
3 
4 

1 

1 

1 
1 


1 


10 
11 
13 

6 

1 
2 

6 

2 

3 


s 
1 

1 

2 
I 

4 

1 
2 
2 

1 

i 


i 


1 

2 
3 


i 

• 


18 
15 
29 
14 


2 


8 

22 

B 

9 

i 


25 
43 
30 

31 

4 
1 
1 

2 
3 
7 
3 

1 

i 
1 

19 
19 
16 
23 

26 
20 
23 
15 

3 

i 

2 

2 
1 

i 



a Continued fever. 



252 



Sanitary and Meteorological Notes. 



Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 

Table II. exhibits the number of eases of certain infectious 
diseases treated in the Dubhn Hospitals during the week 
ended September 9, 1916, and the number under treatment at 
the close of each of the three preceding weeks. 

Table IL 





1 
No. of Cases in Hospital { 








Diseases 


at close of week ended j 

i 
1 


Week ended Sept. 9 
















No. 
















under 










No. 


Dis- 


Died 


treat- 




Aug. 19 


Aug. 26 Sept. 2 


admitted 


charged 




ment 
















at close 
















of week 


Enteric Fever 


33 


43 


43 


6 


3 


— 


46 


Typhus 


— 


— 


— 


— 


— 


— 


— 


Small-pox - 


— 


— 


— 


— 


— 


— 


— 


Measles 


8 


6 


3 


1 


2 


— 


2 


Scarlet Fever 


36 


35 


36 


14 


5 


— 


45a i 


Diphtheria - 


30 


34 


28 


4 


8 


1 


23 


Pneumonia - 


13 


13 


11 


4 


5 


— 


10 

1 



a Exclusive of 9 patients in " Bcncavin," the Convalescent florae of Cork 
Street Fever Hospital. 

From this Table it appears that the cases admitted to 
hospital during the week ended September 9, and the cases 
under treatment at its close, respectively, were as follows : — 
Enteric fever, 6 and 46 ; measles 1 and 2 ; scarlet fever, 
14 and 45, and diphtheria, 4 and 23. Four cases of pneumonia 
were admitted during the week and 10 remained under treat- 
ment at its close. Of the deaths in hospitals during the week 
one was from diphtheria. 

ENGLAND AND SCOTLAND. 
The mortaUty in the week ended Saturday, September 9, in 
96 large English towns (including London, in which the rate 



Sanitary and Meteorological Notes. 253 

was 11.0), was equal to an average annual death-rate of 11.9 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland was 13.1 per 1,000, the rate for Glasgow 
being 14.2, and that for Edinburgh, 13.9. 

Infectious Diseases in Edinburgh. 
The Registrar- General has been favoured by A. Maxwell 
WiUiamson, M.D., B.Sc, Medical Officer of Health for 
Edinburgh, with a copy of his Return of Infectious Diseases 
notified during the week ended September 9. From this 
Report it appears that of 61 cases notified, 21 were of scarlet 
fever. 15 of pulmonary tuberculosis, 7 of other forms of 
tuberculosis, 15 of diphtheria, and 3 of erysipelas. 
Among the 376 cases of infectious diseases in hospital at the 
close of the week were 139 of pulmonary tuberculosis, 115 of 
scarlet fever, 73 of diphtheria, 10 of measles, 7 of cerebro- 
spinal fever, 6 of enteric fever, 3 of erysipelas, and 2 of puerperal 
fever. 

Meteorology. 
Abstract of Observations made in the City of Dublin, Lat. 53° 20 

N., Long. 6° 15' W., for the month of August, 1916. 
Mean Height of Barometer, - - - 29.910 inches. 

Maximal Height of Barometer (3rd, at 9 a.m.), 30.433 ,, 
]VIinimal Height of Barometer (25th, at 9 p.m.), 29.360 „ 
Mean Dry- bulb Temperature, - - 60.6°. 

Mean Wet-bulb Temperature, - 58.0°. 

Mean Dew-point Temperature, - - 55.6°. 

Mean Elastic Force (Tension) of Aqueous Vapoiu-, .445 inch. 
Mean Humidity, - - - 84.3 per cent. 

Highest Temperatm-e in Shade (on 4th & 12th), 74.0°. 
Lowest Temperature in Shade (on 30th), - 47.3°. 

Lowest Temperature on Grass (Radiation) (30th), 43. 6°. 
Mean Amount of Cloud, - - - 62.2 per cent. 

Rainfall (on 16 days), - - - 2.881 inches. 

Greatest Daily Rainfall (on 27th), - .596 inch. 

General Directions of Wind, - - - W.,N.W.,S.W. 

Eenuirks. 
August, 1916, proved to be a month of distinctl}' high 
temperature (62.3°), but of rather small diurnal range (11.9°). 
The mean percentage of cloud was 62.2, ranging from 68.1 at 



254 Sanitary and Meteorological Notes. 

9 a.m. to 56.3 at 9 p.m. The mean relatilve humidity was 
81.7 per cent, at 9 a.m. and 86. S per cent, at 9 p.m. 

In addition to the liigh mean temperature, the month was 
characterised by a marked prevalence of A\'inds from westerly 
quarters and a high relative humidity (84.3 per cent.). Condi- 
tions were settled and the weather was very fine and warm 
until the 12th, when a Ijroken period set in lasting to the 18th, 
inclusive. A tine spell followed, but from the 23rd the weather 
was again unsettled, and heavy rains fell- — more especially in 
England on the 29th and 30th, when it was fine in Ireland. 
On the 29th the upper clouds (cirrus and cirro-stratus) were 
seen from Dublin to be travelling from S.W., while the lower 
clouds and the surface Avind came from N.E. and N. This is 
noteworthy in connection with the storm and downpour of 
rain -which visited the soutli of England at that time. 

In DubUn the arithmetical mean temperature (62.3'') wis 
2.6° above the average (59.7°). The mean of the dry-bulb 
readings at 9 a.m. and 9 p.m. was 60.6° The mean maximal 
temperature was 68.2° ; the mean minimum was 56.3°. In 
the Hfty years enduig -wdth 1915, August was coldest in 1912 
(M. T. = 54.4°) and in 1881 (M. T. = 57.0°), and warmest 
in 1899 (M. T. = 63.4°). In 1911 the M. T. was 63.2°. In 
1913 it was 59.7°, in 1914, 61.2°, and in 1915, 59.1°. 

The mean height of the barometer Avas 29.910 inches, or 
0.013 inch above the corrected average value for August — 
namely, 29.897 inches. The mercury rose to 30.433 inches at 
9 a.m. of the 3rd, and fell to 29.360 inches at 9 p.m. of the 
25th. The ol)served range of atmospheric pressure was, there- 
fore, 1.073 inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thennometer at 9 a.)n. and 9 p.m. was 60.6°. It was 
1.7° above the value for July, 1916. Using the formula. Mean 
Temp. = Mill -\- (Max. — Jllin.) x .47, the mean tempera- 
ture was 61.9°, or 2.6° above the average mean temperature 
for August, calculated in the same way. in tlu> thirty-five 
years 1871-1905. inclusive (59.3°). The arithmetical mean of 
the maximal and minimal leadings was 62.3°, compared with 
a thirty-five years' average of 59.7°. On the 4th and 12th the 
thermometer in the screen rose to 74.0° — wind, W-N.W. to E. 
on the 4th, and S. to ,S.8.W. on the 12th ; on the 30th the 
thermometer fell to 47.3° — wintl, N.W. The minimum on the 
grass was 43.6° on the 30th. 

The rainfall was 2.881 inches on 16 days. The average 



Sanitary and Mcteorotogicat Notes. 255 

fall for August in the tliiity-five years, 1871-1905, inlcusive, 
was 3.2-iO inches, and the average number of rain-days was 
18. The rainfall, therefore, and the rain-days were slightly 
below the average. In 1900 the rainfall in August was very 
large — 5.871 inches on 17 days ; in 1889, also, 5.747 inches 
were registered on 22 days. On the other hand, in 1884, only 
.777 inch was measured on 8 days. August, 1905, establi.shed 
a record for rainfall in this month in Dublin, for the measure- 
ment was 7.019 inches on 22 days, 3.436 inches having fallen 
on the 25th. In 1913 the rainfall was only .941 inch on 10 
days ; in 1914, it was 3.223 inches on 17 days ; and in 1915, 
it was 2.383 inches on 16 days. 

Fresh winds were noted on 5 days, but never attained the 
force of a gale (8). Fogs occurred on the 5th, 6th and 22nd. 
Temperature reached or exceeded 70° in the screen on 12 days, 
and on 1 day it fell below 50°. A solar halo was seen on the 
2nd, 9th and 10th ; a lunar halo on the 20th. Thunderstorms 
occurred on the 13th, 15th, 26th and 27tli. Hail fell on the 
27th. Lightning was seen on the night of the 1st. A fine 
display of aurora borealis was reported from many parts of 
Ireland between 10 and 11 o'clock on the night of the 26th. 

The rainfall in Dubhn during the eight months ending 
August 31st amounted to 22.031 inches on 152 days, compared 
with 19.265 mches on 134 days in 1915, 14.467 inches on 131 
days in 1914, 16.672 inches on 127 days in 1913, 22.088 inches 
on 150 days in 1912, 11.592 inches on 109 days in 1911, 
24.382 inches on 149 days m 1910, 16.677 inches on 119 days 
in 1909, 17.244 inches on 135 days in 1908, 16.588 inches on 
146 days in 1907, 15.425 inches on 139 days in 1906, only 9.455 
inches on 96 days during the same period in 1887, and a 
thirty-five years' average (1871-1905) of 17.950 inches on 
131 days. 

At the Normal Climatological Station in Trinity College, 
Dublin, the observer, Mr. T. Mulock Bentley, reports that the 
mean value of the readings of the dry-bulb thermometer at 
9 a.m. and 9 p.m. was 61.9°. The arithmetical mean of the 
daily maximal and minimal temperatures was also 61.9°, the 
mean maximum bemg 69.0°, and the mean minimum 54.7°. The 
screened thermometers rose to 76° on the 4th and 10th, and 
feU to 45° on the 30th. On the 8th the grass minimum was 
40.0°. Rain fell on 16 days to the amount of 2.704 inches, the 
greatest fail in 24 hours being 0.526 inch on the 27 Lh. The 



256 Samtary and Meteorohijical Notes. 

duration of bright sunshine, according to the Campbell-Stokes 
recorder, was 143.3 hours, of which 11.2 hours occurred on the 
2nd. The mean daily duration was 4.6 hours. The mean 
sub-soil temperatures at 9 a.m. were — at 1 ft., 62.9° ; at 
4 ft., 59.2°. 

At Ardgillan, Balbriggan (210 feet above sea-level), Captain 
Edward Taylor, D.L., registered 1.89 inches of rain on 14 days, 
the greatest fall in 24 hours being 0.38 inch on the 26th, The 
rainfall was 1.59 inches below the average of 21 years (3.48 
inclies), while the rain-daj^s were 3 below the average. Since 
January 1, 1916, 20.76 inches of rain have fallen at Ardgillan 
on 149 days, the measurement being 2.10 inches and the rain- 
days 25 more than the average. The thermometers in the 
screen rose to 74.9° on the 10th, and fell to 44.8° on the 30th. 
The wettest August at Ardgillan was in 1905, when 6.89 
inches fell on 22 days ; the driest was in 1913, when only 
0.41 inch fell on 9 daj^s. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dublin, was 2.395 inches on 15 days. The 
heaviest fall in 24 hours was 0.505 inch on the 24th. The rain- 
fall at Malahide in 1916 so far amounts to 19.845 inches on 147 
days, being somewhat in excess of the average for the first 
8 months of the year. 

At Stirling, Clonee, Co. Meath (231 feet above the sea), Mr. 
J. Pilkington recorded a rainfall of 3.29 inches on 17 days. 
The largest measurement on any one day was 0.52 inch on 
the 23rd ; 0.50 inch fell on the 27th, the result ot a thunder- 
shower. In the eight months ended August 31, the rainfall 
at Clonee measured 24.43 inches on 155 days, compared with 
17.55 inches on 122 days in the same period of 1914, and 
19.57 inches on 121 days in 1915. 

At the Ordnance Survey Office, Phoenix Park, rain fell on 
16 days to the amoimt of 2.968 inches, the greatest rainfall in 
the 24 hours being 0.486 inch on the 23rd. The total duration 
of bright sunshine was 154.7 hours, the greatest daily sunshine 
being 13.2 hours on the 2nd. The thermometer rose to 75.7° 
in the screen on the 4th, and fell to 43.8° on the 8th. 

Miss Mary Love measured 3.01 inches of rain on 15 days at 
Cheeverstown Convalescent Home, Clondalkin, Co. Dublin, 
the largest record in 24 hours being 0.67 inch on the 17th. 
On the 14th 0.57 inch fell, and 0.50 incli on the 15th. 

Mr. F. Dudley Joynt recorded a rainfall of 2.225 inches on 



Sanitary and Meteorological Notrst. 



257 



14 days at 89 Anglesea Road, Donny brook, Dublin. The 
greatest fall in 24 hours was 0.500 inch, which occurred on the 
23rd. On the loth there was a fall of 0.480 inch. 

Dr. Arthur S. Goff reports that at Belfort House, Dundrum, 
Co. Dubhn, rain fell on 16 days to the amount of 2.87 inches, 
the greatest daity fall being 0.62 inch on the 13th. Thunder 
and lightning occurred in the Dundrum district on the 13th, 
loth, 26th and 27th. The mean shade temperature was 63.4°, 
the thermometer rising to 79° on the 4th and 10th, and falling 
to 48* on the 30th. 

According to Mr. W. J. jM'Cabe, the observer for the Right 
Hon. Laurence Waldron, at Marino, Killiney, Co. Dublin, 
2.04 inches of rain fell on 13 days. The maximal fall in 24 
hours was .46 inch on the 23rd. The average rainfall at 
Cloneevin, Killiney, in August of the twenty -four j'ears, 
1884-1907, was 3.212 inches on 16.8 days. 

Mr. Harold Fajde forwards the following abstract of 
observations made by him during August at Rosedale, Shankill, 
Co. Dublin :— 

Mean corrected Height of Barometer, - 29.911 inches. 

Highest corrected Readmg (4th, 8 hours), - 30.41 ,, 
Lowest corrected Readmg (25th, 20 hours), - 29.37 ,, 
Mean Dry-bulb Temperature, - - - 59.0°. 

Mean Wet-bulb Temperature, - - 56.8°. 

Mean Vapour Pressure, - - - 0.430 inch. 

Mean Humidity. - - - - 87 per cent. 

Mean Maximum Temperature, - - 66.4°. 

Mean Minimum Temperature, - - 54.0°. 

Arithmetical Mean Temperature, - - 60.2°. 

Highest Temperature in Screen (1st), - - 74°. 

Lowest Temperature in Screen (8th), - - 44°. 

Lowest Temperature on Grass (30th), - 42°. 

Rainfall (on 14 days), - - - - 1.96 inches. 

Greatest Daily Rainfall f23rd), - - 0.41 inch. 

Mean Amount of Cloud, - - - 67.1 per cent. 

Daj's of Clear Sky, - - - - 2. 

Days of Overcast Sk5^ - - - 12. 

Nights of Ground Frost, - - - 0. 

General Directions of Wind, - - - W., S.W. 

According to Dr. J. H. M. Armstrong, at Coolagad, Grey- 
stones, Co. Wicklow, the rainfall was 2.63 inches on 16 days. 



258 Sanitary and Meteorological Notes. 

The heaviest fall in 24 hours was 0.43 inch on the 22nd. The 
total fall since January 1 amounts to 26.54 inches on 151 days. 
Thunder was heard on the 15th, 16th, 26th and 27th. Sheet 
hghtning was seen from 8 to 9 p.m. of the 24th. On the 29th 
and 31st the Welsh mountains were seen. There was a sea-fog 
on the 5th. The shaded thermometer rose to 74° on the 1st 
and feU to 50° on the 29th. 

At Auburn, Greystones, Co. Wicklow, Mrs. Sydney O'Sullivan 
recorded a rainfall of 3.79 inches on 14 days. The greatest 
measurement in 24 hours was 0.93 inch on the 1st. 

At the Royal National Hospital for Consum])tion for 
Ireland, Newcastle, Co. Wicklow, Dr. F. O'B. Kennedy, 
Resident INIedical Officer, reports that rain fell to the amount 
of 1.94 inches on 15 days, the greatest daily rainfall being 0.62 
inch on the 25th. The screened thermometers rose to 75° on 
the 1st, and fell to 49° on the 18th and 30th. The mean 
maximal temperature was 67.4°, the mean minimal tempera- 
ture was 54.4°, and the mean temperature was 60.9°. 

The Rev. Canon Arthur Wilson returns the rainfall at the 
Rectory, Dunmanway, Co. Cork, at 6.64 inches on 17 days. 
The largest measurements in 24 hours were 1.49 inches on the 
22nd ; 1.31 inches on the 26th ; 1.04 inches on the 27th ; 0.90 
inch on the 13th, and 0.58 inch on the 11th. The first 10 days 
were very fine and warm. For the 30 days from July 12th to 
August 10th, inclusive, the rainfall Avas only 0.13 inch {i.e., 0.08 
inch on July 15th, 0.04 inch on August 1st, and .01 inch on 
August 5th). This was probably the lowest fall for 30 conse- 
cutive days since May, 1896, when Colonel Shuldham reported 
0.10 inch for the whole month of May. 

There was a break in the weather on the 1 1th for three days. 
It was then very fine and warm till the 22nd. The heavy 
rains of the 11th and 22nd fell at night, and the falls on the 
13th, 26th and 27th consisted of very heavy showers with 
bright intervals. On Sunday, the 27th, one inch fell in 2 or 3 
showers between 9 30 a.m. and 1 30 p.m. After this the 
weather was very fine and warm again till the afternoon of 
the 31st. The rainfall in 1916 to August 31st has been 34.70 
inches, or 1.57 inches less than the average (36.27 inches) for 
thf> first eight months of the year. The number of rain- 
day in 1!)16 up to August 31st has been 148, 



PERISCOPE. 

DELETERIOUS LIQUIDS OR SUBSTANCES, 



Articles sent for Medical Examination or Analysis. 



The Secretary, General Post Office, London, under date 
August 21st, ^1916, informs us that the follo^\ing regulations 
have been substituted for those printed at page 21 of the Post 
Office Guide, and are now in force : — Deleterious liquids or sub- 
stances, though otherwise prohibited from transmission by 
post, may be sent for medical examination or analysis to a 
recognised Medical Laboratory or Institute, whether or not 
belonging to a public health authority, or to a qualified 
medical practitioner or veterinary surgeon within the LTnited 
Kingdom, by letter post, and on no account by parcel joost, 
under the following conditions : — Any such liquid or substance 
must be enclosed in a receptacle, hermetically sealed or other- 
wise securely closed, which receptacle must itself be placed 
in a strong wooden, leather, or metal case in such a way that 
it cannot shift about, and with a sufficient quantity of some 
absorbent material (such as saw-dust or cotton wool) so packed 
about the receptacle as absolutely to prevent any possible 
leakage from the package in the event of damage to the 
receptacle. The packet so made up must be conspicuously 
marked " Fragile with care," and bear the words " Pathological 
Specimen." Any packet of the kind found in the parcel post, 
or found in the letter post not packed and marked as directed, 
will be at once stopped and destroyed \Wtli all its wrappings 
and enclosures. Further, any person who sends by post a 
deleterious liquid or substance for medical examination or 
analysis otherwise than as provided by these regulations is 
liable to prosecution. If receptacles are supplied by a 
laboratory or institute, they should be submitted to the 
Secretary, General Post Office, in order to ascertain whether 
they are regarded as comphing N\'ith the regulations. 



260 Periscope. 

OPTOCHIN HYDROCHLORIDE. 

The Therapeutic Review (Vol. IV., No. 2) quotes with approval, 
from the Neio York Medical Journal, a record of the treatment 
of twenty-four successful cases of pneumonia by the adminis- 
tration of optochin in 0.25 gramme doses every four hours 
by day and night. On the second day the temperature fell 
and the patients made uneventful recoveries. The chemical, 
however, produced the unpleasantness of tinnitus aurium, 
visual disturbance, and diarrhoea. Some four years ago Sir 
Almroth Wright conducted some experiments with optochin. 
He found that the drug acted as a germicide on pneumono- 
cocci in vitro, and on infected mice, but produced little, if any, 
effect on pneumonia in the human being. This negative result 
is probably due to the fact that the coagulation of the blood 
serum in the human air cells protects the pneumonococci. 
Dr. N. Leech used both the hydrochloride and the salicylate of 
the ethyl-hydrocupreine, of which optochin is the registered 
fancy name. Cupreine and its salts possess for us both an 
historical and a therapeutic interest. When, in the eighties, a 
corner was made of cinchona bark, and as a consequence 
quinine cost 20s. to 30s. an ounce, the introduction into the 
market of Remijia bark saved the situation. And it is just 
possible that it was powdered cujDrea bark that Don Francisco 
Lopez de Canizares, the Corrigedor of Loxa, sent to the Lady 
Francisca Henriquez de Ribera, wife of the Count de la 
Chinchon, Viceroy of Peru, in 1638 ; and whicli was administered 
by her physician, Don Juan de Vega. Cupreine and 
quinine are closely allied, quinine being methyl -cupreine. 
C^,, Hg^ N^ O2 = quinine ; C,;, H^^ N^ O^ = cupreine. The abstrac- 
tion of methyl from quinine, however, produces apoquinine, not 
cupreine. Cupreine is only half as toxic as quinine and less active 
physiologically. Both alkaloids produce the same effects. It is 
interesting to note that Charles Darwin {Insectiverous Plants, 
1875) refers to the toxic properties of quinine on many forms of 
protoplasm, and gives an instance from which it appears that 
a solution of one in one thousand of sulphate of quinine with 
basic reaction rapidly destro3^s the tentacles of the Drosera 
rot undif alia. Although both quinine and cupreine are toxic, 
recoveries from very large doses of the former and more toxic 
alkaloid are recorded, Giacomini records tlie recovery of a 



Periscope. 261 

man forty-five years of age who took by mistake 180 grains of 
tlio 8iilp}iate. His face, lips and limbs were blanched and 
cold ; pulse slow and hardly perceptible ; respiration infre- 
quent ; loss of sight and hearing, even after consciousness 
returns. On the fifth day the patient got up, but it was 
" a long time " before recovery took place. 

A PRIZE OF 50,000 FRANCS FOR THE BEST MECHANICAL HAND- 
APPARATUS. 

A GENEROUS donor, who wishes to remain anonymous, has 
offered to the Societe Nationale de Chinu'gie, Paris, a prize of 
50,000 fr. to be handed over to '' the maker of the mechanical 
apparatus best supplying the place of the hand. All com- 
petitors must belong to AlUed or Neutral Nations. They are 
to present to the Society mutilated men who have been using 
their apparatus for at least six months. The Societe de 
Chirurgie will experiment with each apparatus on mutilated 
men for the length of time it thinks fit. The apparatus awarded 
the prize is to remain the property of its inventor. The com- 
petition will be closed two years after the end of the war." 
MM. Faure, Kirmisson, Quenu, Rieffel and Rochard, who make 
up the committee elected by the Societe de Chirurgie, inform 
the public of the condition of the competition as stated by the 
donor, and beg any person wishing to compete to send his 
memoir and apparatus to M. le Secretaire General de la 
Societe Nationale de Chirurgie, a Paris, 12, rue de Seine. 

• 

THE INTERMEDIATE HOST OF YELLOW FEVER. 

There has not been a single case of yellow fever in the United 
States of America since 1905 {Pacific Medical Journal, Vol. 
LIX., No. 4). It is difficult to realise what this means. To 
those famiHar with the history of the ravages of the " Nova 
Pestis " of Barbadoes of 1647, which spread from Quebec to 
Chili and from Spain along the West Coast of Africa to the 
Cap3 of Good Hox)3, it speaks of a victory of Peace which may 
be classed with, that of Jenner. The conquest of the malignant 
fever was a very gradiial process, the outcome of careful 
observation and the development of the science of bacteriology. 
Doctor Charles Finlay was too much advanced to secure the 
acceptance of his observation that the fever was caused by a 
mosquito : Stegomyia fasciata ; but his views gained no 
credence until the publication by the New Sydenham Society's 

T 



262 Perisco'pe. 

translation of Dr. A. Laveran's great work on " Paludism " re- 
excited interest in the life history of the Anopheles. In 1901 
Dr. Gorgas demonstrated in Havanna that yellow fever was 
not infections, and that the excretions of patients suffering 
from it did not convey the fever. Withal, difficulties still 
obscured the path mitil in 1906 the members of the French 
Yellow Fever Commission in Rio de Janeiro discovered why 
persons bitten by day did not develop yellow fever, while those 
bitten by night do. How lethal the stiiig of the pestiferous 
gnat is may be judged of by the fact that in September, 1884, 
the whole crew of a British brig, stationed at Colon, died from 
yellow fever. 

AN IRISH MEMORIAL TO EDITH CAVELL. 

The Board of the Royal City of Dubhn Hospital have receiv^ed 
a cheque for £200 from the honorary secretary of the Edith 
Cavell Memorial, for the purpose of ultimately endowing an 
Edith Cavell bed in the institution. A bed therefore is being 
opened and named without delay, though it is still hoped that 
the further sum of £300 may be raised so as to make the endow- 
ment a jiermanent one. It is an opportunity for the women 
of Ireland which will soon pass if it be not acted upon, for in 
a great war like the present events follow one another in quick 
succession. While these lines are being written, in fact. 
Captain Charles Fryatt's fate is announced, and already 
comparisons are being made between it and Edith Cavell's. — 
The Hospital, August 5, 1916. 

A DUBLIN CHARITY AND THE LATE REBELLION. 

One of the Dublin charities which performs, among other 
things, Samaritan work in connection with the Dublin hospitals 
is the Mendicity Institution. This, as its disagreeable name 
imi^lies, is an old-established organisation which sends patients 
back to their homes when they are vmable to find their fares 
on being discharged, and also helps those who for a similar 
reason are unable to return home from the metropolis after a 
vain search for work, or can find it only at a distance. The 
institution had a lively time during the Sinn Fein Rebellion, 
for it was occupied by Sinn Feiners and eventually consider- 
ably injured. As a result of the wrecking a claim for full 
compensation has been lodged, to repay for the rebuilding 
of the old institution. — The Hospital, August 5, 1916, 



PART IV. 



MEDICAL EDUCATION AND EXAMINATIONS 
IN IRELAND. 

1916-1917. 

Medical students in Ireland, as elsewhere, have in tlie first 
instance to choose between University Degrees and Non- 
University Qualifications or Diplomas. Should they elect 
to try for a University Degree, their choice must lie 
between the University of Dublin, which requires a Degree 
in Arts before registrable Degrees in Medicine, Surgery, and 
Midwifery are conferred ; the National University of Ireland, 
which — while not re(|uii'iiig an Arts Degree — requires all 
students to pass a Matriculation Examination in Arts, before 
a candidate enters upon the curriculum in the three branches 
of Medicine already mentioned — Medicine, Surgery, and 
Midwifery ; and the Queen's University of Belfast, in which 
also a Matriculation Examination in Arts is required. 
Under the Regulations of the School of Phvsic in Ireland 
considerable Professional Privileges are afforded to medical 
students in regard to the Arts Curriculum of the University 
of Dublin. 

Outside the Universities, the chief Licensing Bodies are 
the Royal Colleges of Physicians and Surgeons. The 
position of the Apothecaries' Hall of Dublin as a Licensing 
Corporation under the Medical Act of 1886 has been defined 
by the appointment of Examiners in Surgery by the General 
Medical Council at the l)iddiug of His Majesty's Privy 
Council. 

The Royal Colleges of Physicians and Surgeons are in a 
position to give a first-class working qualification in Medicine, 
Surgery, and Midwifery — a qualification which is registrable 
under the Medical Acts, which is universally recognised as one 



264 Medical Edaeatioii and Examinations in Ireland. 

of high merit, and the possession of which is attended by no 
disabilities, such as preventing its possessor from dispensing 
medicines or keeping open shop for the sale of medicines, if 
he is legally qualified to do so. 

The Medical Schools in Ireland are — (1.) The School of 
Physic in Ireland, Trinity College, Dublin ; (2.) The Schools 
of Surgery of the Royal College of Surgeons in Ireland 
(including the Carmichael College of Medicine and the 
Ledwich School of Medicine) ; (3.) The University College 
Medical School, Cecilia-street, Dublin ; (4.) The Faculty of 
Medicine, Queen's University of Belfast ; (5.) The School of 
Medicine, University College, Cork; and (6.) The School of 
Medicine, University College, Galway. 

Facilities for Clinical Instruction in fully-equipped Medico- 
Chirurgical Hospitals exist in Dublin, Belfast, Cork, and 
Galway ; but, as a rule, the Schools of Medicine in Ireland 
are not attached to a given hospital, or vice versa, as is the 
case in London and other large centres of medical education. 
The student will, however, have little difficulty in selecting 
a hospital, in the wards of which he will receive excellent 
bedside teaching and have ample opportunity of making 
himself familiar with the aspect and treatment of disease. 

The detailed information which follows is authentic, being 
taken directly from the published Calendars of the respective 
licensing bodies. 



REGULATIONS PRESCRIBED BY THE GENERAL 
MEDICAL COUNCIL. 

With regard to the course of Study and Examinations which 
persons desirous of qualifying for the Medical Profession shall go 
through in order that they may become possessed of the requisite 
knowledge and skill for the efficient practice of the Profession, 
the General Medical Council has resolved that the following con- 
ditions ought to he enforced without exception on all Avho com- 
mence their Medical Studies at any time after Jan. 1, 1892: — 

(a.) The period of Professional Studies, between the date of 
Registration as a Medical Student and the date of Final Examina- 
tion for any Diploma which entitles its bearer to be registered 
under the Medical Acts, must be a period of bond fide study 



Medical Education and Examinations in Ireland. 265 

during not less than five years. For the purpose of this require- 
ment the close of the fifth year may be reckoned as occurring 
at the expiration of fifty-seven months from the date of regi8- 
tration. 

{b.) In every course of Professional study and Examinations, 
the following subjects nmst be contained: — 

(I.) Physics, includiug the Elementary Mechanics of Solids and 
Fluids, and the Rudiments of Heat, Light, and Elec- 
tricity. 
(II.) Chemistry, including the principles of the Science, and the 

details which bear on the study of Medicine. 
(III.) Elementary Biology. 
(IV.) Anatomy. 
(V.) Physiology. 
(VI.) Materia Medica and Pharmacy. 
(VII.) Pathology. 
(VIII.) Pharmacology and Therapeutics. 

(IX.) Medicine, including Medical Anatomy and Clinical Medicine. 
(X.) Surgery, including Surgical Anatomy and Clinical Surgery. 
(XI.) Midwifery, including Diseases peculiar to Women and to 
New-born Children. [By a recent decision of the General 
Medical Council the study of (XI.) must not commence 
till the student has held the posts of Clinical Clerk and 
Surgical Dresser.] 
(XII.) Theory and Practice of Vaccination. 
(XIII.) Forensic Medicine. 
(XIV.) Hygiene. 
(XV.) Mental Disease. 
(XVI.) An;psthetic8. 

The General Medical Council considers that the Regulations of 
the Examining Bodies should be so framed as to ensure that the 
study of the Final Group of Subjects (VII. to XVI. above) sbHll 
extend over a period of not less than tAventy-four months after the 
passing of the Examination in Anatomy and Physiology. 

The first four of the five years of Medical Study should be 
passed at a School or Schools of Medicine recognised by any of 
the Licensing Bodies, provided that the First Year may be passed 
at a University, or at a Teaching Institution, recognised by any of 
the Licensing Bodies and approved by the Council, where the 
subjects of Physics, Chemistry, and Biology are taught. 

A student who lias, previous to registratiun, attended a course 
or courses of study in one or all of the subjects, Physics, Chemistry, 
or Biology, in any University, School of Medicine, oi- Teaching 
Institution recognised by any of the Licensing Bodies, may without 
further attendance be admitted to examination in these subjects. 



26Q Medical Education and Examinations in Ireland. 

A graduate in Arts or Science of any University recognised by 
the General Medical Council, who has spent a year in the study of 
Physics, Chemistry, and Biology, and has passed an examination 
in these subjects for the degrees in question, is held to have com- 
pleted the first of the five years of medical study. 

Six months' insti'uction or more in the Preliminary Sciences at a 
Teaching Institution (other than a Medical School) recognised by 
one of the Licensing Bodies and approved by the Council may 
count as six months, and no more, of the Curriculum of Professional 
Study, provided such instruction is subsequent to the date of 
passing the required Preliminary Examination in general education. 

The Examinations in tlie Elements of Pliysics, Chemistry, and 
Biology should be passed before tlie beginning of the Second 
Winter Session. 

The General Medical Council considers that no Qualification in 
Medicine ought to be granted without evidence of Clinical 
Instruction in Infectious Diseases. 

The Genex-al Medical Covmcil also considers that Instruction 
should be given, in the Courses of Forensic Medicine and Public 
Health, or otherwise, on the duties which devolve upon Practitioners 
in their relationship to the State, and on the generally recognised 
rules of Medical Ethics. Attention should be called to all Notices 
on these subjects issued by the (Tencral Medical Council. 



I. 
University of Dublin. 

DEGREES AND DIPLOMAS IN MEDICINE, SUKGEKY, AND 
MIDWIFERY ; AND IN DENTISTRY. 

The Medical School of the University of DubUn has for its 
official title the name of The School of Physic in Ireland. It is 
officered by University Professors and Examiners and by four 
King's Professors appointed by the President and Fellows of the 
Royal College of Physicians of Ireland, acting as Trustees of the 
Estate of Sir Patrick Dun. 

Matriculation. 

Students cannot be permitted to attend any of the Courses of 
Instruction in the School of Physic in Ireland until they have 
matriculated. There is no special Kxamination ; the Public 
Entrance and Term Examinations of Trinity College, or any otlier 



Medical Education and Examinations in Ireland. 267 

of the Prelimiuary Examinations recognised by the General Medical 
Council, being accepted as equivalent. The Matriculation Fee 
is Five Shillings. It is not necessary for Students to have their 
names on the College Books, or to attend any of the Academical 
duties of the University, unconnected with the School of Physic, 
unless they desire to obtain a Diploma or Degree in Medicine, 
Surgery, and Midwifery. Students may matriculate at tl»e 
commencement of either the Winter or the Summer Session. 
The 17th of November is the last day of admission to the Winter 
Session. In the Summer Session the last day of admission varies a 
good deal according to the time at Avhich Easter occurs, and the 
Courses of Lectures for which the Student proposes to enter. 

WOMEN STUDENTS. 

Women Students are now admitted to the Degrees and 
Diplomas in Medicine, Surgerj', and Midwifery", on the same 
conditions as men, A special Anatomical Department, with 
separate entrance, dissecting-room and a reading-room, has 
been erected by the Board of Trinit}- College for their 
accommodation. 

Qualifications. 

The Quahfications in Medicine, Surgery, and Midwifery, and in 
Dental Science, granted by the University are as follow : — 
The Degrees are : — 

1. Bachelor in Medicine. 

2. Bachelor in Surgery. 

3. Bachelor in Obstetric Science. 

4. Doctor in Medicine. 

5. Master in Surgery. 

6. Master in Obstetric Science. 

7. Bachelor in Dental Science. 

8. Master in Dental Science. 

The Diplomas are : — 

1. Diploma in Public Health (formerly Qualifica- 

tion in State Medicine). 

2. Diploma in Medicine. 

3. Diploma in Surgery. 

4. Diploma in Obstetric Science. 

Final Medical Examination. — Part I. 
The subjects are — Pathology, Materia Medica and Therapeutics, 
Medical Jurisprudence and Hygiene. 



268 Medical Education and Exaininations in Jretand. 

Before they are admitted to the Examination, Students must 
have attended the prescribed Courses of Study, passed the Inter- 
mediate Medical Examination, Part II., and paid the Liceat 
Fee (£5). =* 

Vaccination (Fee, £1 Is.) should be taken out in tLe fourth 
year. 

Final Medical Examination. — Part II. 

The subjects are — (a) Medicine, Clinical Medicine, and Mental 
Disease ; (6) Surgery, Clinical Surgery, Surgical Operations, and 
Ophthalmic Surgery ; (c) Midwifery and Gynaecology (clinical, 
papers, and viva voce). 

Candidates for the Final in Siu'gery will be required to produce 
a certificate of instruction and practice in the administration of 
General Amesthetics. 

Students may present themselves for Examination in any of 
these groups (a), (6) or (c), separately or together, at any of 
the Examinations during their Fifth Year ; but they must leave 
at least one of these groups until the end of their Fifth Year. 
Before presenting themselves for any of these groups, Students 
must have attended all the prescribed Courses of Instruction in 
the subject in which they present themselves for Examination, 
and paid the Liceat Fee (£5).'^ Candidates in any group who fail 
to satisfy the Clinical Examiners are not permitted to proceed 
with the other parts of the Examination. 

Total Expenses of the Required Courses. 

I. Lectures . . . . . . £67 4 

II. Hospitals . . . . . . 55 13 

III. Degrees (M.B., B.Ch., B.A.O.) . . 27 



Total . . . , . . £149 17 

university diim-omas. 

Candidates tor the Diploiiuis in Medicine, Surgery, and Obste- 
tric Science, must be matriculated in Medicine, and must have com- 
pleted two years in Arts, and five years in Medical Studies. 

The dates, regulations, and sul)jects of Examination are the 
same as for the Degrees. 

Diploinates on completing the Course in Arts, and proceeding 

■ Liceat foes aro. not cliarj^od to students who have matriculated in 
the Sthool of Pliysio subsequent to May 22nd, 1915. 



Meillcal J^dacation and Examinations in Ireland. 269 

to the Degree of B.A., may be admitted to the Degree of Bachelor 
on paying the Degree Fees. 

The Liceat fees are the same as for the Final Kxaininations for 
the Degrees/"* 

Candidates who have completed the prescribed Courses of 
study and passed all the Examinations, will be entitled, if Grad- 
uates in Arts, to have conferred on them the Degrees of M.B., 
B.Ch., B.A 0.. on payment to the Senior Proctor of the Degree 
Fees amounting to £17. A corresponding regulation applies to 
the Diplomas, the Fees for which are £11. They vAW also obtain 
from the Senior Proctor a Diploma entithng them to be entered 
on the Register of Medical Practitioners under the Medical Act, 
1886. 

DIPLOMA IN PUBLIC HEALTH, OR STATE MEDICINE. 

In the year 1870 a "Diplomii in State Medicine" was instituted 
by a resolution of the Board of Trinity College. In 1898 it was 
resoked that the title of the '' Diploma in State IMedicine " be 
changed to that of " Diploma in Public Health." 

The Diploma in Public Health is conferred, after examination, 
by the University of Dublin, upon Candidates fulfilling the 
conditions required by the General Medical Council. 



II. 
The Nationat. University of Ireland. 

THE MATRICULATION EXAiUXATIOX. 

This Examination will be held in Dublin, and at certain local 
Centres selected by the Senate. 

Extract from the Statutes of the University. 

The University may grant the following Degrees to Students 
who, under conditions laid do^vn in the Statutes and Regu- 
lations, have completed Approved Courses of Study of the 

* Liceat fees are not cbargcd to students who have matriculated in 
the School of Physic subsequent to May 22nd, 1915. 



270 Medical Education and Examinations in Ireland. 

prescribed duration, and have passed the Prescribed Examina- 
tions of the University and fulfilled all other prescribed 
conditions. 

IN THE FACULTY OP MEDICINE. 

Bachelor of Medicine (M.B.), Bachelor of Surgery (B.Ch.) 
Bachelor of Obstetrics (B.A.O.) 

Bachelor of Science, Public Health (B.Sc, Pubhc Health). 
Master of Surgery (M.Ch.) 
Master of Obstetrics (M.A.O.) 
Doctor of Medicine (M.D.) 

Doctor of Science, Public Health (D.Sc, Public Health). 
Bachelor of Dental Surgery (B.D.S.) 
Master of Dental Surgery (M.D.S.) 
The Degrees of M.B., B.Ch., and B.A.O. shall be conferred 
only at the same time and after the same Course of Study. 
A Student shall not be admitted to the Final Examination for 
these Degrees unless he — 

(a) shall have completed the prescribed Course of Study 
in the Faculty of Medicine, extending over a period 
of not less than five academic years from the date 
of his registration as a Student of Medicine by the 
General Medical Council ; 
(6) shall have passed the prescribed Examinations ; and 
(c) shall have attained the age of 21 years. 
The Senate shall not confer the Degrees of M.B., B.Ch., 
and B.A.O. upon an}^ person who has not jsursued at the 
University, or in one or more of its Constituent Colleges, during 
at least Nine Terms, the Courses of Study prescribed for such 
Degrees. The. Senate may accept the periods of Study pursued 
in any other University or School of Medicine recognised for 
this purpose b}' the Senate, equivalent in duration to not 
more than Six Terms, as equivalent to part of such Approved 
Course of Study. The periods of Study so accepted shall be 
deemed to have been Terms kept Avithin the meaning of the 
Statute. 

Regulations for Courses of Study and Examinations for 
Degrees in the Faculty of Medicine. 

DEGREES OF BACHELOR OF MEDICINE (M.E.), BACHELOR OF 
SURGERY (J^Cii.), BACHELOR OF OBSTETRICS (B.A.O.) 

General Regidalions. 
1. Candidates for the Degrees of M.B., B.Ch., and B.A.O. 



Medical Education and Examinations in Ireland. 271 

shall be required to pass four University Examinations, after 
Matriculation, namely : — 

(1) The First Universit}^ Examination in Medicine ; 

(2) The Second University Examination in Medicine ; 

(3) The Third University Examination in Medicine ; 

(4) The Final Examination for the Degree of M.B., 

B.Ch., and B.A.O. 

2. Honom's may be awarded at each of the Examinations. 

3. The Courses of instruction required to be attended in 
the subjects for each of the Examinations for the Degrees of 
M.B., B.Ch., and B.A.O. shall be attended and completed in 
accoi-dance ^^^th the Regulations of the University. 

COURSES OF INSTRUCTION AND SUBJECTS OF EXAMINATIONS 
FOR THE DEGREES OF M.B., B.Ch., AND B.A.O. 

The Course of Medical Studies shall be divided into five 
Periods of one Medical year each, during which Periods the 
Students shall attend the Courses set forth in the List of 
Courses for the Degrees of M.B., B.Ch., and B.A.O. for the 
respective years and according to the Regulations for the 
Examinations. 

I. Courses of the First Year and First Exajunation 
IN Medicine. 

1. The subjects of the Fu-st Examination in Medicine 
shall be : — 

(1) Chemistry, and Practical Chemistry. 

(2) Experimental Ph3'sics. 

(3) Zoolog3\ 

(4) Botany. 

2. (a) Candidates Avho have passed the First University 
Examination in Science in the subjects of the First Examina- 
tion in Medicine A\ill, on payment of the required additional 
fee, be regarded as having passed the First Examination in 
Medicine. 

(6) Candidates who have passed an Examination in Arts 
in the subjects of the First Examination in Medicine wiU be 
regarded as having passed in those subjects for the First 
Examination in Medicine. 

3. Candidates for admission to the First University Exami- 
nation m Medicine must have attended the prescribed Courses 



272 Medical Education and ^.vaminations in Ireland. 

of instrviction in the subjects of the Examination, as set 
forth in the College Syllabus of Courses for Degrees in Medic me. 
4. The Examination wiU be divided into two parts as 
follows : — 

Part I. Chemistry, Practical Chemistry and Experi- 
mental Physics, including laboratory work. 

Part II. Botany and Zoology, including laboratory work. 
Part I. and Part II. are not necessarily to be taken at the 
same Exammation, and Candidates may obtain credit if the 
standard of answering is deemed sufficient for either Part I. or 
Part II. Honours will not be awarded, in either Part, unless 
the Examination is passed as a whole at one time. 

II. Courses of the Second Yeab, and Second 

Examination in Medicine. 

The subjects of the Second Examination in Medicine shall 
be:— 

Anatomy, and Practical Anatomy. 
Physiology, and Practical Physiology. 

1 . Candidates for the Second Examination in Medicme must 
have passed the First Examination in Medicine, and must 
have attended the prescribed Courses of instruction in the 
subjects of the Second Examination in Medicine as set forth 
in the College Syllabus of Courses for Degrees in Medicine. 

2. Candidates who have complied with the Conch tions in 
Section 1 , may present themselves for the Second Examination 
at the end of their second year. 

Note. — Courses of Anatomy are required both in the first 
and second years. 

III. Courses of the Third Year, and the Third 

Examination in Medicink. 
The subjects of the Third Examination in Medicine shall 
be :— 

( 1 ) I'alliology and Klcmetitary Bacteriology, and Practical 

Pathology. 

(2) Materia Medica, Pharmacy, and Therapeutics. 
(3) -Hygiene (Sanitary Science). 

(4) Medical .liiiispnidence. 
1. C!andidates for the Third h^xamiuation in Medicine must 
have passed the Se(!ond Examination in Medicine, and must 



Medical Educatiun and Examinations in Ireland. 273 

have attended the prescribed Courses of instruction of tlie 
Third Examination in Medicme, as set forth in the College 
Syllabus of Courses for Degrees in Medicine. 

2. Candidates duly qualiiied may present themselves for 
the Third Examniation in Medicine not earUer than the end 
of their third Medical year. 

Note. — See for Hospital i\ttendance, under the heading 
Third Year, page 275. 

IV. Courses of the Fourth and Fifth Years, and the 
Final Examination in Medicine i-or the Degrees 
OF M.B., B.Ch., B.A.O. 

The subjects of the Final Examination are as follows : — 

(1) Medicine, Systematic and Clinical. 

(2) Surgery, Systematic, Clmical and Operative. 

(3) Midwifery and Gynaecology, Systematic and Practical. 

(4) Ophthalmology and Otology, Systematic and Clinical. 
The Examination may be taken m two parts, namely : — 

Part I. Medicine and Pathology.* 

Part II. IMidwifery and Gynaecology, Surgery, and Ophthal- 
mology and Otology. 

Neither Part I. nor Part II. can be taken before the end 
of the Fifth Year. Either Part, or both Parts, may be taken 
at the same period of Examination. 

Note. — See for Hospital Attendance and other Courses of 
the Fourth and Fifth Years. 

Candidates for the Final Examination must have passed 
the Third Examination in Medicine. They must have attended 
the prescribed Courses of Instruction for the Final Examination, 
and must have compUed with aU the requirements m respect 
of Hospital attendance and otherwise, as set forth below. 

Students are requested to note that the study of the subjects 
included in the Third and Final Examinations must extend 
over a period of not less than 24 months after the 'passing of 
the Examination in Anatomy and Physiology. 

» Only Candidates who passed the Third Medical Examination after 
Spring 1915 are required to present themselves for Examination in this 
subject. 



274 Medical Education and E.vaniinations in Ireland. 

LIST OF COURSES OF INSTRUCTION PRESCRIBED 
FOR THE DEGREES OF M.B., B.Ch., B.A.O. 

First Year. 
Winter. (Michaelmas and Hilary Terms.) 

1. Anatomy. ( Required for the Second 

2. Practical Anatomy. ( Examination. 

3. Chemistry. 

4. Practical Chemistry. 

5. Exi3erimental Physics, \\\l\\ Laboratory Course. 

6. Botany ^Hilary Term). 

7. Zoology (First part of Practical Course). 

Note. — Courses 1 and 2 in Winter are not reqviired for the 
Fnst Examination in Medicine, but must be taken in the first 
year to permit a CancUdate to qualify for admission to the 
Second Exammation in Medicme at the end of the second year. 

Sumtner. (Trinity Term.) 

1. Zoology. 

2. Practical Zoology. 

3. Botany. 

4. Practical Botany. 

Second Year. 
Winter. (Michaelmas and Hilary Terms.) 

1. Anatomy. 

2. Practical Anatomy. 

3. Phj'siology. 

4. Practical Physiology (Physical and Chemical). 

Summer. (Trinity Term.) 

1. Anatomy. 

2. Practical Anatomy. 

3. Physiology. 

4. Practical Histology. 

TurRD Year. 
Winter. (Michaelmas and Hilary Terms.) 

1 . Pathology. 

2. Singer}', or Mcilicine. 

3. Hygiene. 

4. I'ractical Pliannacy. 



Medical Kdncation and Examinations in Ireland. 275 

Summer. (Trinity Term.) 

1. Materia Medica and Therapeutics 

2. Practical Pathology. 

3. Medical Jurisprudence. 

In addition to the Courses above. 
Hospital Practice with CUnical Instruction : — 

(1) Attendance during nine months (Winter and Summer) 

at a General Hospital recognised by the University, 
and at the Clinical Lectures deUvered therein. 

(2) Six Months' Surgical Dressing at the Hospital, or, if 

divided into two periods of three months each, one 
period may be taken in the Fourth Year. See (2) 
beloM', under Fourth Year. 
See Certificates required for Hospital Courses, page 277. 

Fourth Year. 
Winter. (Michaelmas and Hilary Terms.) 

1. Medicine, of Surgery. (The subject to be that not taken 

in the Third Year.) 

2. Midwifery and Gjaiaecology. 

3. Pathology (Hilary Term only). 

Summer. (Trinity Term.) 

1. Operative Surgery. 

2. Applied Anatomy. 

3. Ophthalmology and Otology. 

In addition to the Courses above, 
Hospital Practice with CHnical Instruction : — 

(1) Attendance during nine months (Winter and Summer) 

at a recognised General Hospital and at the Clinical 
Lectures deUvered therein. 

(2) The office of CHnical Medical Clerk must be held for 

six months at the Hospital in the Fourth Year, or, 
if divided into two periods of three months each, 
one period may be taken in the Fifth Year. If the 
Clinical Medical Clerkship be taken in the Third 
Year, the Surgical Dressership may be taken in 
the Fourth Year. 



276 Meclieal Education and E.caniinations hi Ireland. 

Fifth Yeae. 

(J) Hospital Practice with Clinical Instruction. Attend- 
ance during nine months (Winter and Summer) at 
a recognised General Hospital and at the Clinical 
Lectures delivered therein, to complete the twenty- 
seven months' required attendance at cUnical 
instruction m a General Hospital. 

(2) Practical Midwifery and Gynaecology. Attendance 

during six months at a Midwifery Hospital recog- 
nised by the University, where Clinical Instruction 
is given. Every student, before commencing the 
study of Practical Midwifery, must have held the 
offices of Clinical Medical Clerk and Surgical 
Dresser, and must have attended the courses of 
lectures on Surgery and Midwifery (See Third and 
Fovirth Years above). Every student will be 
required to present a certificate that he has con- 
ducted twenty cases of labour imder official Medical 
supervision. 

(3) Attendance during three months at a recognised Fever 

Hospital or at the Fever Wards of a General 
Hospital, similarly recognised. The student must 
have had personal charge as Clinical Clerk of at 
least ten cases. 

The attendance at a Fever Hospital does not 
count as part of the twenty-seven months' of 
Clinical Instruction required of all students. 

Attendance on Fever cases must not take place 
during attendance on Practical Midwifery and 
Gynaecology. 

(4) CUnical Ophthalmology and Otology. Three months' 

attendance at a recognised Ophthalmic Hospital. 

(5) Mental Diseases. Three months' attendance at an 

Asyhun for Mental Diseases recognised by the 
University. 

(6) Vaccination. A course of practical instruction under 

a Public Vaccinator, 

(7) Gynaecological Clerkship, for three months. 

(8) CUnical Instruction in the methods of administration 

of Anaesthetics. 

(9) Attendance on at least six post-mortem Examinations. 



Afedical Educatio)i and E.vaminations in Ireland. 211 

With the exception of the three separate i)eriods of nine 
months' General Hosiiital Attendance to complete the pre- 
scribed twenty-seven months, in the Third, Fourth, and Fifth 
years, the Courses set out under the Fourth and Fifth 
years may be taken in a different order in regard to those 
years, provided that the regulations in respect of the Courses 
which must precede Practical Midwifery and Gynaecology are 
observed, and that the Course in Fever Cases is not concurrent 
with Practical IVIidwifery. 

The sj'stematic Courses of Medicine, Surgery, and Midwifery 
should be taken in the Winter of the Tliird and Fourth Years, 
as set out above. 



Summary of Certificates required in connection with 
Hospital Courses and other Non-Collegiate Courses. 



Tl 



e following Certificates will be required ; — 

1) Certificates of attendance at a General Hospital for 

three periods of nine months each, as above. 

2) Certificate as Dresser in Surgery for six months. 

3) Certificate as Chnical Clerk in Medicine for six months. 

4) Certificate of the conduction of twenty cases in 

Practical Mdwiferj^, and of attendance for six 
Months at a Mid^^ifery Hospital. 

5) Certificate of Gjiiaecological Clerk for three months. 

6) Certificate and Notes of Fever Cases for three months 

(ten cases). 

7) Certificate of practice in Vaccination. 

8) Certificate of attendance at six Post-mortem Examina- 

tions. 

9) Certificate of Chnical Ophthalmology and Otology 

for three montlis. 

0) Certificate of attendance at a Lunatic Asylum and 

Notes of Cases. 

1) Certificate of attendance at Chnical Listruction in 

Anaesthetics. 

u 



278 Medical Education and Exa7mnations in Ireland. 

III. 
Thk Queen's University of Belfast. 

DEGREES IN THE FACULTY OF MEDICINE. 
Statutes. 

1. There shall be six degrees of the University in the Faculty 
of Medicine, vi^. : — 

Bachelor of Medicine (M.B.), 
Bachelor of Surgery (B.Ch.), 
Bachelor of Obstetrics (B.A.O.), 
Doctor of Medicine (M.D.), 
Master of Surgery (M.Ch.), and 
Master of Obstetrics (M.A.O.). 

2. The degrees of M.B., B.Ch., and B.A.G. shall be the primary 
degrees in the Faculty of Medicine, and shall be conferred at the 
same time and after the same course of study. No student shall 
be admitted to the final Examination for these degrees until he 
has shown (1) that he is a Matriculated Student of the University, 
(2) that he has completed the prescribed course of study in the 
Faculty of Medicine extending over a period of not less than five 
academic years from the date of his registration as a Student of 
Medicine by the General Council of Medical Education and 
Registration of the United Kingdom, and (3) that he has passed 
the several examinations prescribed. 

3. The Senate shall not confer the primary degrees in the 
Faculty of Medicine upon any person who has not attended in the 
University during three academic years at least the courses of 
study prescribed for such degrees. The Senate may accept, for 
not more than two academic years of the required five, courses of 
study pursued in any other University or School of Medicine 
approved by the Senate. 

4. Every candidate for the primary degrees in Medicine shall 
be required to show that he has attained the age of twenty-one 
years on or before the day of graduation. 

5. The degrees of M.D., M.Ch., M.A.O. shall not be conferred, 
nor shall any of them, until the exph'ation of at least three 
academic years, or in the case of graduates of the University in 
Arts or Science of at least two academic years, after admission to 
the primary degrees in the Faculty of Medicine. Every candidate 
must show that in the interval he has pursued such courses of 
study or been engaged in such practical work as may be prescribed. 
Any of these degrees may be conferred by the Senate either (a) 



Medical Education and Examinations in Ireland 279 

after an examination or (6) on the submission of a thesis or other 
evidence of original study or research to be approved by the 
Faculty of Medicine after an oral or other examination of the 
candidate on the subject thereof. 

Regulations. 
1. All candidates for the Degrees of M.B., B.Cli., and B.A.O. 
shall be required to have satisfied the Examiners in the several 
subjects of four examinations, namely : — 
The First Medical Examination. 
The Second ]Medical Examination. 
The Third Medical Examination. 
The Fourth Medical Examination. 
Two Examinations will be held during the year. 
Candidates will not be allowed to present theruselves for more 
than one of the Medical Examinations at the same time. 

THE DEGREE OF DOCTOR OF MEDICIXE. 
Regulations. 

1. The Degree of Doctor of Medicine shall not be conferred until 
the expiration of at least three academic years, or in the case of 
graduates of the University in Arts or Science of at least two 
academic years, after admission to the primary degrees in the 
Faculty of Medicine. Every candidate must show that in the 
interval he has pm'sued such courses of study, or been engaged in 
such practical work as may be prescribed. This Degree may be 
conferred by the Senate either (a) after an examination, or (6) on 
the submission of a thesis or other evidence of original study or 
research, to be approved by the Faculty of Medicine after an oral 
or other examination of the candidate on the subject thereof. 

2. The subjects of the examination under (a) shall be : — 
The Principles and Practice of Medicine, and one other 

special subject to be selected by the candidate. 
The special subjects shall be as follows : — 
i. Human Anatomy, including Embrj'-ology. 

ii. Physiology. 

iii. Pathology 

iv. Pharmacology and Therapeutics. 

V. Sanitary Science and Public Health. 

vi. Forensic Medicine and Toxicology. 

vii. Mental Diseases. 
The examination in Medicine shall include : — 

(a) A written paper. 

[h) A commentary upon a selected clinical case or cases. 

((') A clinical and vivd voce examination. 



280 Medical Education and Exmninations in Ireland. 

Tlie examination in the Special Subjects shall include : — 
(a) A written paper, 
(fe) A clinical or practical and viva voce examination. 



THE DEGREE OF MASTER OF SURGERY. 
Regulations. 

1. The Degree of Master of Surgery shall not be conferred until 
the expiration of at least three academic years, or in the case of 
graduates of the University in Arts or Science of at least two 
academic years, after admission to the primary degrees in the 
Faculty of Medicine. Every candidate must show that in the 
interval he has pursued such com-ses of study or been engaged 
in such practical work as may be prescribed. This Degree may 
be conferred by the Senate either (a) after an examination, or (6) 
on the submission of a thesis or other evidence of original study 
or research, to be approved by the Faculty of Medicine after an 
oral or other examination of the candidate on the subject thereof. 

2, The subjects of the examination under (a) shall be: — 

(1) Surgery, Theoretical and Practical, including Ophthal- 

mology and Otology. 

(2) Surgical Pathology. 

(3) Sm'gical Anatomy and Operative Surgery, with the use 

of Surgical Instruments and Appliances. 
There shall be both written and oral examinations in these 
branches, and a clinical examination upon selected surgical cases. 



THE DEGREE OF MASTER OF OBSTETRICS. 

Regulations. 
1. The Degree of Master of Obstetrics shall not be conferred 
until the expiration of at least three academic years, or in the case 
of graduates of the University in Arts or Science, of at least two 
academic years after admission to the primary degrees in the 
Faculty of Medi(;ine. Every candidate must show that in the 
interval he has pursued such courses of study or been engaged 
in such practical work as may be prescribed. This Degree may 
be conferred by the Senate either («) after an examination, or 
{h) on the submission of a thesis or other evidence of original study 
or research, to be approved by the Faculty of Medicine after an 
oral or other examination of the candidate on the subject thereof. 



Medical Educalion and E.ramiiKitions in Ireland. 281 

2. The subjects of the examiuatioa under (a) sliall be: — 

(1) Midwifery. 

(2) Diseases of Women and Children. 

(3) Pathology in its special bearing on Midwifery and Diseases 

of Women and Childi-en. 
The examination shall consist of : — 
(1) A written examination. 
(?) A clinical examination. 

(3) An oral examination with practical illustrations, including 
those of instruments and appliances. 

THE DIPLOMA IN PUBLIC HEALTH. 

St.-vtute. 

The Senate may confer Diplomas in Public Health upon legally 
qualified medical practitioners who have pursued such com-ses of 
study and passed such examinations as may be prescribed : 
Provided always that the Kegulations for such study and examina- 
tions are in accordance \\ith the rules made from time to time by 
the General Council of Medical Education and Registration of the 
United Kingdom. 

Examinations. 

Two examinations will be held yearly, and will consist of two 
parts. Candidates may present themselves for either part 
separately, or for both parts together at their option. 

The Calendar giving all necessary information regarding 
entrance, examinations, lectures, fees, scholai'ships, prizes, &c., 
may be obtained, price 1/- to students. 



IV. 

Royal Colleges of Physicians and Surgeons, 
Ireland. 

regulations for the examinations in medicine, 

SURGERY, AND MIDWIFERY REQUIRED FOR REGIS- 
TRATION UNDER THE MEDICAL ACT. 1880. 

I'hese Regulations are obligatory on all Candidates commencing their 
Studies on or after October 1st, 1902. 



Preliminary Examination. 



REGULATIONS. 



The following are the subjects of Examination : — 
I. Latin. 



282 Medical Education and Kxaminatiom^ in Ireland. 

II. Any one of the following languages : — Greek, Frencli, 
German, Italian, Lish, Dutch, Spanish, or any other 
modern language approved by the Board of 
Examiners. 

III. EngUsh. 

IV. Elementary Mathematics. 

The Candidate, when entering his name, is required to state in 
what Language selected from II. he desires to be examined. 

If he desires to be examined in Dutch, he must send, at least a 
month before the Examination, notice of the portions of the Dutch 
Authi^irs he has selected. 

A Candidate who proposes to be examined in a Modern Language 
other than French, German, Italian, Irish, Spanish, or Dutch 
must give notice of his proposal at least three months before the 
Examination. 

1. The following works are prescribed in English till 
December 31st, 1917 :— 

(a) Shakespeare - Merchant of Venice. 
{h) Macaulay - Chapter III. cf History of England. 
(c) Tennyson - Ulysses, Tithonus, Dream of Fair 
Women. 

2. Grammar and Analysis of Sentences. 

3. Paraphrase of an unprepared passage, to test the Candidate's 
power to ajjprehend its meaning. 

4. History and Geogi-aphy. 

5. Essay. 

The Examination in Mathematics embraces Arithmetic. 
Algebra — Definitions and Explanations of Algebraical Signs and 
Terms. Addition, Subtraction, Multiplication, and Division. 
Simple Equations in one unknown quantity. Easy Problems. 
Geometry — The subjects covered by Euclid, Books 1, 2, 3 ; 
and Book 4, Propositions 1, 2, 3, 4 and 5, with some additional 
Elementary Practical Constructions, and some Elementary loci. 
Geometrical methods other than those followed by Euclid will be 
accepted, such as regarding tangents as limiting positions of 
choids, &c. Candidates are required to provide themselves with 
a ruler, set square, jnotractor, and pencil compasses. 

N.B. — (Jandidates are reminded that great importance is attached 
to unprescribed translation, and to composition, at all Examinations 
of which these subjects form a part. Preparation of the prescribed 
aul/iors alone will not secure Pass marled. 



Medical Education and Exauiuiations in Ireland. 283 

The Exaniiuatiou shall be coiuliicted cutiioly >)}■ written papers. 

A book of questions set at the Preliminary Examinations 
held during each previous year h^hall be available for issue to 
Candidates. Price 6d. ; post free 6id. 

Marks 
Marks shall be allotted as under : — 

Latin .. .. , 120 marks. 

English .; 180 „ 

Greek, or alternative language . . . . 120 ,, 

Mathematics 120 

1. Candidates who pass in all sTibjects, and are awarded seventy 
per cent, of the total marks obtainable, are placed in a separate 
list, and are considered to have passed with " Honours.'' 

2. A Candidate may get credit for every subject in which he 
obtains pass marks, provided he passes in all foui' subjects at 
not more than two Examinations. He can offer himself for re- 
examination as often as may be necessary to satisfy this condition. 

3. Candidates who hold the complete Pass CeriificaTe of 
the Senior Grade, or the Middle Grade Examination with 
Honours in three subjects, of the Intermediate Education Board 
of Ii'claud, may complete the Preliminary Examination under the 
Conjoint Board by passing in any subject or subjects required 
by the General Medical Council which are not passed at the 
Intermediate Examination. 

4. The fee for the first admission of a Candidate to the 
Examination shall be Two Guineas. Fee for each subsequent 
admission — One Guinea. 

Proof of Age. 

No Candidate shall be admissil)le to the Preliminary Examina- 
tion who does not prodiice evidence of having attained the age 
of sixteen 3'ears on or before the first day of the Examination. 

Dates of Preliminary Examinations for 1917. 
Wednesday— March 7th, June 13th, and October 3rd, 1917. 
The Examinations are held at the KoA-al College of Surgeons, 
St. Stephen's Green. Dublin, commencing each day at 10 a.m. 

Preliminary Examinations accepted by the Colleges. 
All Examinations in General Education recognised by the 
General Medical Council (a Ust of wliich will be found in the 



284 Medical Education and Examinations in Ireland, 

Kegister of Medical Studonts) are accepted by the Colleges in lieu 
of the Preliminary Examination held by them. Information as 
to such Examinations may be obtained at the Branch Medical 
Council OfHce, 35 Dawson tStreet, Dublin. 



PKOFKSSIONAL EXAMINATIONS. 

Every Candidate is required to pass four Professional Examina- 
tions. 

Candidates will be admissible to the various Examinations 
as under : — 

First Professional Examination, not earher than the end of the 

first winter session. (Fee is £15 15s.) 
Second Professional Examination, not earlier than the end of 

the second winter session. (Fee is £10 10s.) 
Third Professional Examination, not earUer than the end of the 

third year of medical study. (Fee is £9 Os.) 
Final Professional Examination, not earlier than the end of the 
fourth year of medical study ; but it cannot be completed 
till the end of the fifth year of medical study. 
No Candidate shall be admitted to any Examination within 
three months of his rejection in the subjects of that Examination 
by this or any other Licensing Body. 

Final Professional Examination. 
The Fee for this Examination is £6 6s. 
The subjects of the Final Professional Examination are : — 

Division A.^ — Medicine, including Fevers, Mental Diseases, 

and Diseases of Children. 
Division B.— Surgery, including Operative Surgery and 

Ophthalmic Surgery. 
Division C. — Midwifery and Gynaecology, Vaccination, 

and Diseases of New-born Children. 

Before admission to the Final Professional Examination, 
every Candidate must have ])assed in the subjects of the Third 
Professional Examination. 

Candidates are recommended to present themselves in all the 
subjects of the Final Examination at one time ; but a Candidate 
at or after the end of the fourth year may present himself in 
any one of the J)ivisions A, B, or C, ])rovided he has completed 



Medical Education and Examiimtions in Jrehwd. 2S5 

his Curriculum as far as concerns the Division in wiiicii he 
l^resents himself. The Examination in at least one of the 
Divisions must be deferred till the end of the fifth year. 

Before completing the Final Examination a Candidate must 
have passed four years in Medical Studies other than those 
for the First Professional Examination. 

Candidates must have passed in all the subjects of the Final 
Exammation before any Diploma can be granted. 

Each Candidate before receiving his Diplomas must produce 
a Registrar's Certificate, or other satisfactory evidence, that he 
has attained the age of twenty-one years. 

EXEMPTIONS. 

Candidates who have passed in any of the required subjects at 
Examinations conducted by any Licensing Body recognised by 
the Royal College of Physicians and the Royal College of Surgeons 
may, at the discretion of the Committee of Management, be 
exempted from further examination in such subjects under these 
Regulations. 

REGULATIONS FOR CANDIDATES FOR THE DIPLOMA 
IX PUBLIC HEALTH. 

Stated Examinations for the Diploma in Public Health com- 
mence on the first Monday of the months of February, May, July, 
and November. 

A special Examination for the Diploma may, at the discretion 
of the Committee of Management, be obtained — except during 
the months of August and September — on application at least 
one fortnight before the date of the proposed Examination, and 
payment of £15 15s. in addition to the ordinary Fees mentioned 
below. 

Every Candidate for the Diploma in PubUc Health must be a 
Registered Medical Practitioner. He must retiu-n his name to 
the Secretary of the Committee of Management under the Con- 
joint Scheme, Royal College of Surgeons. Dublin, one fortnight 
before the Examination, and lodge with him a Testimonial of 
Character from a Fellow of either of the Colleges, or of the Royal 
Colleges of Physicians or Surgeons of London or Edinburgh, 
together with certificates of the prescribed course of study. 

Candidates registered as Medical Practitioners or entitled to be 



286 Medical Edncation and Exayninations in Ireland. 

so rf^gistered after January 1st, 1890, must comply with certain 
Resolutions and Rules, adopted by the General Medical Council . 

The Fee for the Examination is Ten Guineas, which must be 
lodged in the Ulster Bank, Dublin, to the credit of the Committee 
of Management. Fees are not returned to any Candidate who 
withdraws from, or is rejected at, any Examination. The Fee 
for re -examination is Five Guineas, 

The Examination for the Diploma in Pubhc Health comprises 
the following subjects : — Chemistry and Physics, Engineering 
and Architecture, Meteorology, Sanitary Law, Vital Statistics, 
Hygiene, Bacteriology. 



V. 

Apothecaries' Hall of Dublin. 

The Primary, Intermediate and Final Examinations are held 
three times a year — viz., commencing the first Monday in 
March, June, and November. 

The Fees payable for each Examination are as follow : — 

Primary Professional . . . . ..£550 

Intermediate „ 10 10 

Final Examination . . . . . . 15 15 

A Candidate is allowed for each Professional Examination which 
he has completed at any other recognised Licensing Body, except 
the Final. 

Ladies who comply with the regulations will be admitted to 
these examinations. 

Candidates may be admitted to a Special Examination, under 
special circumstances, which must be laid before the Examination 
Committee. If the Candidate's application be granted, .'in extra 
fee of Ten Guineas over and above the full fee is required. 

Candidates already on the Register will receive the Diploma 
of the Hall on passing an Exaniination in Medicine, Materia Medica 
and Pharmacy. 

Each Candidate, before receiving his Diploma, must produce 
evidence that he lias attained the age of twenty-one years. 

Licentiates of this Hall are entitled to enter as Candidates for 
the Fellowship of the Edinburgh Royal College of Surgeons. 

All information relative to the Examinations may be obtained 
from the Rogistrar of the Apothecaries' Hall, 40 Mary Street, 
Dublin. 



Medical Kducaiion and E.raminations hi Ireland. 287 

VI. 
Dental Education and Examinations in Ireland. 



UNIVEESITY OF DUBLIN. 
DEGREES IN DENTAL SCIENCE 

Combined Arts and Dental Curriculum. 

The University of Dublin grants the degrees of Bachelor and 
Master in Dental Science. 

Either of these qualifications entitles the holder to be registered 
as a licensed Dental Practitioner. 

In order to obtain the Degree of Bachelor (B. Dent. Sc), 
Candidates must have completed the course for the Arts Degree 
(B.A.) of the University and have spent at least four years in the 
School of Dentistry. The Degree of Master in Dental Science 
(M, Dent. Sc.) is awarded after a further examination, and cannot 
be taken until the end of a fifth year of study. 

The Dental and Arts Courses may be taken separately or 
concurrently. 

The Degree of Bachelor in Dental Science is conferred on 
Students who have completed the required Courses and 
Examinations, and passed in Ethics and English Comiiosition 
at an ordinary examination for the B.A. Degree. 

The total fees in order to obtain the degree of Bachelor in 
Dental Science are : — 

Entrance fee, Arts fees (4 years), and fee 

for B.A. Degree £83 4 

Lectures, Laboratory, and Hospital fees 186 18 

Exanuuation fee , . . . . . . . 5 

Fee for Degree . . . . . . , 10 



£285 2 



MASTER IN DENTAL SCIENCE. 



Candidates for the Degree of Master in Dental Science must be 
Bachelors in Dental Science of at least one year's standing. 
They will be required to pass an examination in Pathology and 
Bacteriology, and either to carry out Dental work of an advanced 



288 Medical Education <nul K.iuoninaLions in Ireland. 

character to the satisfaction of the Examiners, or to present a 
thesis, to be approved of by them, giving evidence of original 
research on some subject connected with Dentistry. 



ROYAL COLLEGE OF SURGEONS IN IRELAND. 
DIPLOMA IN DENTAL SURGEHY. 

The Royal College of Surgeons in Ireland grants Diplomas in 
Dental Surgery under revised conditions adopted by the Council 
on November 25, 1909, of which the following is a synopsis: — 

The Candidate must be twenty-one years of age before being 
granted the Diploma. 

The Caaididate must have passed tlu*ee Examinations. 

1. Preliminary (identical with the Medical Preliminary). 

2. First Dental. (This Examination is much the same as 
the Second Conjoint Professional.) 

^^. Final Dental Examination. Candidates are examined in 
General Pathology, Medicine and Surgery ; Dental 
Surgery, and Dental Pathology, with tlie Materia 
Medica and Thei-apeutics applicable to Dental Surgery ; 
Dental Mechanics and Metallurgy ; Orthodontia. 

Ijarge reductions in the Special Certificates required are made 
in the cases of qualified Medical Practitioners.'* 

» Fuller particulars can be obtained by application to the Registrar, 
Royal College of Surgeons, St. Stephen's Green, Dublin. 



LITERARY NOTE. 

" Pulmonary Tuberculosis in General Practice," by Dr. 
Halliday Sutherland, Medical Officer to the St. Marylebone 
Tuberculosis Dispensary, is announced for immediate publica- 
tion by Messrs. Cassell & Co., Ltd., Publishers, La Belle 
Sauvage, London, E.G. 



THE DUBLIN JOURNAL 



f 



OF 



MEDICAL SCIENCE. 

NOVEMBER 1, 1916. 

PART I. 
OKIGINAL COMMUNICATIONS. 



Art. XIV. — Fractures arid Fracture Dislocations.^ By 
John S. M'Aedle, M.Ch. (Hoji. Causa) R.U.I., 
F.R.U.I., F.R.C.S.I. ; Professor of Surgery, National 
University of Ireland; Senior Surgeon, St. Vincent's 
Hospital; Consulting Surgeon, National Hospital, 
Holies Street, and Children's Hospital, Temple Street, 
Dublin. (Illustrated.) 

{Continued from Volume CXLIL, page 79.) 

Feactures of the Boxes of the Forearm. 

At one of the recent examinations I asked the simple 
question : How would you treat fracture of both bones 
of the forearm below the insertion of the biceps tendon? 
The answer revealed woeful ignorance. " I would apply 
plaster bandage and keep the forearm flexed." Now, if 
anything could be the opposite of sound surgery this is 
just it. 

* A Course of Lectures on Clinical Surgery delivered at St. Vin- 
cent's Hospital, Dublin. 

VOL. CXLII. — NO. 539, THIRD SERIES. Y 



290 



Fractures and Fracture Dislocatiuns. 



The golden rule in the treatment of fractures of the 
radius and ulna, or of both of these bones, is : after 
reducing the fracture^ keep the hones apart — the reason 
for this is : that any fixation between the radius and ulna 
renders pronation and supination impossible, and necessi- 




)=■ E r«i u R 




HOMER us 



G 



RAO' us 



MET A CAB PA. 8. 9 

Fig. 26. 



tates vigorous surgical measures if the Hmb is to become 
functionally useful. 

Such a procedure you saw me carry out in the case of 
the patient in No. 11 bed. The gravity of the procedure 
has been greatly lessened since the days when such cases 
were treated by suture, as sliown in Plate XI., Fig. 25, 
that was by se])arating the bones, refreshing the ends, and 
wiring. Such an ()])eration is tedious, entails extensive 
dissection, aiul requires a large wound area, thus (as the 



Mr. John S. M'Ardlk. — Fractures and F mature Dislocations. 

PLATE XI. 




Yic. 2;") 




Fig. m. 



Bv Mr. John S. M'Ardle. 



291 



late Dr. J. B. Murphy pointed out) materially increasing 
the danger of local devitalisation and wound infection, 
conditions which delay healing, and often lead to complete 
failure. 

The introduction of metal plates instead marked a gTeat 
advance. Later, the use of partially decalcified bone 

FEMUR S, KNEE 




±iG. 27. 



plates, held in position by bone screws, still further helped 
us to secure almost perfect results. But now, one attacks 
these cases with the utmost confidence, as there is at 
our disposal a very rapid method, which is capable of re- 
storing the bone line and leaving no foreign body to inter- 
fere with muscular action. 

The bone pegs which I show you, and which you have 
seen me employ, vary in thickness, according to the size 
of the fractured bone. As a rule, a bone two inches long 



292 Fractures and Fracture Dislocations. 

and six millimetres thick suffices for the forearm bones. 
I like unpolished pieces, and for choice porous ones, rather 
than ones that are eburnated. 

I have used transplanted portions of the tibial crest, but 
see no advantage in them over those you have seen me 
employ with success. Still, another method demands 
attention, that is, the very rapid fixation of the fragments 
by metal bridges (as shown in Fig. 27). You see they are 
of many sizes, and their points are of varying lengths to 
suit different situations. 

In dealing with recent fractures they are very effective, 
and when driven home they interfere very little with the 
action of superimposed muscles. To render driving easy 
and safe, a small drill hole should be made. This can be 
done rapidly with the drill I now show you. The opera- 
tion is very rapid; a straight incision is made down to the 
bone, the soft tissues are held apart with retractors, the 
bones are supported by toothed bone retractors, and driving 
of the metal bridge completes the procedure. Elevators 
are not necessary in recent fractures, these hooks slip 
round the bone, and no contusion of the soft parts takes 
place during their use. 

I would warn you that in ancient fractures — either for 
non-union or malposition — I do not use these bridges, as re- 
pair is slow, and before it is complete absorption round the 
points may render the bridge loose. If you make up your 
mind to use a bone peg in an old-standing fracture, have 
by you a drill, with burrs as you see here (Fig. 28), so 
that if the medullary canal is closed by callus, you can 
make a place for the peg. 

The canal in the upper fragment must be made the 
full depth of the peg, in the other, only half that depth. 
This enables one to slide the peg well up out of the way, 
and- then, while adjusting, a sharp hook brings it down 
into the lower fragment. These pegs form an admirable 
scaffolding for the developing new bone. 

When both bones of the forearm are broken in the adult 
T am satisfied tlial ))lating is the proper treatment, and 



Mr. John S. M'Aedle. — Fractures and Fracture Disloratious. 

PLATE XII. 




Fio. 31. 




Fig. 32. 



By Mr. J. S. M'Aedlb. 



293 



the plates should be applied on the posterior edge of the 
ulna and the outer side of the radius. In the young, 
plating is not necessary, as rapid union occurs if the bones 
are supported by a broad posterior splint, and a narrow 
anterior interosseous one, which presses the flexor muscles 
well between the bones, so as to keep them widely apart. 
In all these fractures flexion and semipronation should 
be maintained. There are three nniscles which play an 





Fig. 28. 



important part in all fractures of the forearm — the 
biceps, the pronator radii teres, and the pronator quadra- 
tus. When a fracture occurs below^ the insertion of the 
biceps the upper fragment is drawn upwards, and rotated 
outwards, while the lower is drawn inwards by the 
pronator teres, with a corresponding rotation. This case 
is dealt with by a splint such as is here shown (Fig. 29), a 
special interosseous pad being fitted along the forearm, 
and a straight posterior splint, one inch wide, between the 
radius and ulna on the posterior aspect. 



294 



Fractures and Fracture Dislocations. 



The next fractures to which I wish to call your attention 
are those occurring at the lower end of the radius. Plate 
XI., Fig. 30, shows a fracture simulating a " Colles," but 
the treatment of which should be the opposite of that ad- 
vocated for those immediately above the radio-carpal line. 
In this case a straight hand and an anterior interosseous 
narrow splint secured perfect adjustment. Traction to- 
wards the ulnar side would here be fatal to a perfect result. 

Fractures occurring at the higher level than the one just 
described require immediate plating if we are to have 
success. When the lower fragment is left to the unin- 




FiG. 29. 



fluenced action of the pronator quadratus, this piece of 
the radius is drawn towards the ulna, and, becoming fixed 
thereto, pronation and supination are lost. Plate XII., 
Fig. 31, shows the result in a case of this kind. The patient, 
a keen sportsman, could not align his gun owing to fixation 
of the radius to the ulna. I was obliged to separate the 
bones by chiselling and to apply the plate shown in the 
picture. I have had the pleasure of seeing this patient 
during the present season shoot better than ever, pronation 
and supination being perfect. 

When any doubt exists as to the type of fracture an 
aj-ray should be obtained, and two views are necessary, 
because in one the line may seem (piite good, while the 
other may show marked se|)aration of the fragments. Plate 
XIT., Fig. 3"2, shows a "Colics" in ii fair ])osition in 



Me. John S. M'Aedle. — Fractures and Fracture Dislocations 

PLATE XIII. 





I r \ e- 



Fig. C3. 



!l'i'^'^^H3!UP*.A„^--i.f»»;^ 




m 



Mo\ 5 



Fir.. 34. 



'Mn. John S. M'Ardle. — Fractures tHK] Fracliirc Dislocations. 



PLATE XIV. 




Fig, 3;^ 




Fig. 36. 



Heliotherapy in Tuberculosis. 295 

anlero-posterior view, while the lateral view (Plate XIII., 
Fig. 33) shows a position so faulty that I was obliged to 
carry out a grave operation for the restoration of function 
in the forearm. This patient has since played in and won 
the greatest polo match of the Century. 

The next case I would call your attention to so 
simulated a ' ' Colles ' ' that it was treated by applying two 
straight splints, and Plate XIII., Fig. 34, shows the result 
when the patient came under my care three weeks after the 
accident. This was a fracture by direct violence, and, as 
you can see, the bone is broken a long way from the radio- 
carpal joint. Extension and the application of a broad 
posterior and narrow anterior interosseous splint secured 
a very good union. 

When examining injuries of the forearm bones at the 
lower end in the aged be careful least you do more harm 
than good. Violent manipulation may lead to disimpaction 
should the case be such as I now show you (Plate XIV., 
Fig. 35). Here any interference in the way of so-called 
setting of the bones could only be harmful ; the line of the 
bones is all right, and the lateral view (Plate XIV., Fig. 
36) shows onl}^ a slight projection of the lower end of the 
radius which occasioned very little trouble after treatment. 

Early passive movement, support by gamgee tissue, and 
gentle massage secured an admirable result. 



Art. XV. — Heliotlierapij in Tuberculosis of the Bones 
and Joints.^ By Eileen Mabel Hewitt, M.D., B.Ch., 
B.A.O., B.A., Univ. Dubl. 

It has now been universally recognised for a long time that 
the treatment of surgical tuberculosis must not be local onlj^ 
but that every means at our command must be employed 
to improve the nutrition of the body and to increase the 
resisting power of the tissues. The fact that sunlight is of 

* A Thesis read for the Degree of Doctor of Medicine ia the 
University of Dublin, June, 1916. 



296 Heliotherapy in Tuherculosis. 

value in this respect has now been proved ; fresh air and 
sunshine, preferably at a high altitude, in conjunction with 
perfect hygiene and sanitation and good food, have been 
shown to be more valuable than all the drugs at our dis- 
posal. 

Finsen, Willard and Freudenthal are amongst the 
earliest who report success in the treatment of surgical 
tuberculosis with sunlight. In recent years the subject 
has been drawn attention to chiefly by Dr. A. EoUier, 
of Leysin, Switzerland. In England, Dr. H. J. Gauvain has 
reported favourable results from the employment of helio- 
therapy. Dr. Gauvain, to whom I have had the privilege 
of acting as assistant during the past year, has now em- 
ployed this form of treatment for some eight years at the 
Lord Mayor Treloar Cripples' Hospital, Alton, Hants. 

The degree of success depends largely on the climate ; if 
possible, a place should be chosen where the duration of 
sunlight is prolonged, the rainfall low, and high winds and 
fog are infrequent. Kollier, in particular, has drawn atten- 
tion to these factors; but, at the same time, after long 
experience he has come to the conclusion that sun treat- 
ment may have beneficial effects in any locality. 

Light Energy and its Bactericidal Power. — Sunlight is 
made up of at least three different kinds of rays, viz. : — 

1. Calorific or heat rays, which occur in and below the 
red end of the spectrum. 

2. Luminous or light rays, which occur chiefly in the 
yellow part of the spectrum. 

3. Actinic or chemical rays, which are found in the violet 
and ultra-violet portions of the spectrum. 

Of these, the calorific and actinic rays are the most im- 
portant therapeutically. The present tendency is rather 
to ascribe all the virtues to the latter ; Snow, on the other 
hand, appears to consider the thermal rays of the first im- 
portance. Clinical results seem to point to the fact that 
a certain combination of these rays is most effective, either 
alone, or, possibly, with some form of energy at present 
unknown. 



By Dr. Eileen Mabel Hewitt. 297 

It has been freely proved experimentally that sunlight 
is able in the presence of oxygen, to inhibit and destroy 
micro-organisms. Koch has demonstrated the destructive 
power of light on the tubercle bacillus. Bernard, Morgan 
and Freund were the first to investigate the bactericidal 
power of sunlight under the conditions governing sun treat- 
ment. Thev found that the penetration of the rays through 
the tissues is not sufficient to allow their bactericidal powers 
to come into action. In their opinion the effect of the rays 
is to increase the physiological resistance rather than to 
actively destrov the micro-organisms. Eecent work tends 
to confirm these conclusions. When the lesion is absolutely 
superficial the bactericidal action is exhibited, as in ex- 
perimental work. 

Sources of Light empJoijecL—As a general rule, for 
therapeutic purposes, the best form of light energy is to 
be obtained from the sun. Sunhght, at its source, is very 
rich in ultra-violet rays, but, during its passage to the earth, 
a large number of these rays are absorbed by the medium 
through which they pass ; hence the chemical activity of 
sunlight is much diminished at the earth's surface. 

Various lamps have been devised to act as " artificial 
suns." Apparently the chief object in their construction 
has been to obtain a maximal amount of chemical energy, 
and the production of those other factors, whatever they 
may ultimately prove to be, which lead to the indirect and 
most important effects, has been neglected. The Hanau 
lamp is used at Alton as a source of ultra-violet light ; it is 
a mercury vapour lamp with a quartz container. A very 
recent lamp constructed for the purpose is the Simpson 
arc lamp, the poles of which are of wolframite. Its advan- 
tages over the mercury vapour lamp have not yet been 
clearly demonstrated. 

Application of the Treatment.— Whilst employing helio- 
therapy for tuberculosis of the bones and joints, it must 
be realised that it cannot replace local treatment ; rational 
conservative measures must be carried out at the same time 
if success is to result. The patient who comes under 



298 Heliotherapy in Tuberculusis. 

treatment must first be gradually accustomed to a liberal 
allowance of fresh air and to a scanty allowance of cloth- 
ing. If he tolerates these changes well, it is safe to com- 
mence sun treatment within the week, provided there are 
no other contra-indications. The patient should be clothed 
in white, and his head should always be well protected. 
The sun baths should be administered in the open air, the 
.sun's rays being allow^ed to fall directly on the patient. 

On the first day, in the average case, the feet and legs,, 
as far as the knees, should be exposed to the sun four or 
five times, for periods of five minutes each, at intervals of 
an hour. The next day the legs may be exposed up to the 
thighs for five and to the knees for ten minutes each hour. 
The dosage is thus gradually increased, so that by the sixth 
day, in the case of a tolerant patient, the whole body may 
be exposed for ten and the legs for twenty minutes each 
hour. As soon as pigmentation is thoroughly established 
the whole body may be exposed continuously. No rigid 
scale of dosage can be drawn up, as patients vary so widely 
in their susceptibility; fair patients, as a rule, are more 
sensitive than dark, and do not pigment so easily. Sensi- 
tive patients develop solar erythema, and blister very 
rapidly ; in such cases the treatment must be proceeded 
with by very slow degrees. Experience alone can regulate 
the dosage to the best advantage. Special attention should 
be paid to the exposure of sinuses ; it is advisable to swab 
them occasionally with tincture of iodine. 

The details of the application of artificial light vary, of 
course, with the strength of the lamp employed. 

Clinical Observations. — The action of sunlight l)rings 
about the deposit of pigment in the skin ; this pigmentation 
is commonly known as sunburn. Pigmentation has a pro- 
tective action ; once it is well established the skin will 
tolerate continuous exposure to strong sunlight ; before 
pigmentation has taken place, if exposure be at all pro- 
longed, the irritative action of the rays causes erythema 
and blistering. Leredde and Pautrier suggest that the 
process of pigmentation may be one of adaptation by which 
the f)r';nnisiii is enabled to iiial\'(> iisi^ of ch'/mical ouerffv in 



By Dr: Eileen INIabel Hewitt. 299 

some unknown form. This suggestion seems to be sup- 
ported by clinical observations made at Alton. It has been 
noticed there that those patients who do not pigment do 
not derive the remote beneficial effects which others do 
from the sun. My attention has recently been drawn to the 
fact that in these cases where the reaction to the sun's rays 
is not manifested bv the deposit of pigment, the prognosis 
must be guarded, irrespective of the clinical signs. In 
such cases extension of the disease appears to occur invari- 
ably, sooner or later. The extension may take, for in- 
stance, the form of an abscess or of a new lesion. After 
such has occurred heliotherapy causes pigmentation, and 
beneficial effects ensue. Well established pigmentation is 
almost always a favourable sign. 

The eliminative and absorptive functions of the skin are 
stimulated by the improvement in the cutaneous circula- 
tion, which occurs under the influence of light. 
' Patients, on the whole, appear brighter and happier after 
sun treatment has commenced. Many children who, up 
to that time, have appeared dull and stupid, become lively 
and talkative. The observations of Finsen many 
years &go established the fact that light has a tonic effect 
on the nervous system. Eollier has observed that the vital 
processes of respiration and circulation are stimulated, and 
that the psychological condition is greatly improved by 
heliotherapy. The increased activity of the vital centres 
is said to be attributable to the fact that the application of 
light energy to the peripheral neurons exerts a reflex in- 
fluence on the deep spinal centres. Many pale and 
cachectic children who come under one's observation, after 
months of fresh air, good food, and suitable local treat- 
ment, reveal little or no sign of improvement ; such children 
often respond well to heliotherapy : the appetite is im- 
proved, the weight increased, and the anaemia lessened. 
This is due to the beneficial effects of light on metabolism 
and on the blood; experimentally, it has been shown that 
light causes increased tissue change, both anabolic and 
catabolic. • Experiments also have demonstrated the fact 
that the oxygenating power of the blood is stimulated by 



300 Heliotherapy in Tuberculosis. 

light energy, particularly by the chemical rays, which it 
is believed to absorb more readily than does any other 
tissue. It is also claimed that the percentage of 
haemoglobin is raised. 

With regard to the effects of heliotherapy on the actual 
tuberculous lesion, oljviously, in the case of joint disease, 
it is possible to obtain perfect functional results only when 
the patient is secured before extensive destruction of tissue 
has occurred ; this must be the case with any form of treat- 
ment. Nevertheless, a considerable amount of useful 
movement returns in many advanced cases where the 
patient has been subjected to helio- and aerotherapy, 
accompanied by rational orthopaedic treatment. In early 
" closed " cases, where the patients pigment readily, the 
disease can generally be rapidly arrested ; the ultimate 
functional results in these cases are excellent. Many joint 
cases, who do not come under treatment till fibrous anky- 
losis has taken place, regain fair movement with sun treat- 
ment. Abscesses are absorbed, and sinuses healed under 
the influence of the sun's rays. Dr. Gauvain has asserted 
that " sinuses which heal after isolation tend to possess 
supple scars with a minimum of keloid." The way in 
which light brings about the spontaneous extrusion of 
sequestra is striking. Dr. Gauvain and Miss De Voss, 
in an article on heliotherapy, describe this interesting pro- 
cess as follows : — " A freely suppurating sinus shows a 
small black spot in its recesses, resembling a coagulum. 
This increases in size, and, pushing the sinus walls apart, 

travels towards the surface Gradually, and 

without discomfort, the sequestrum loosens from its sur- 
roundings, and is extruded. Should tlie insolation be in- 
terrupted by unsuitable weather, the sequestrum, though 
apparently on the point of being expelled, slij^is back again 
into the depths of the sinus." 

Artificial heliotherapy is found at Alton to be of 
greatest benefit when used in conjunction with natural 
heliotherapy. As I have already mentioned, with artificial 
light, the remote beneficial effects, which are procurable 
with natural sunlight, are ajiparcntly not obtained; this is 



By Dk. Eileen Mabel Hewitt. 301 

probably associated with the fact that it is very difficult 
to produce pigmentation by artificial means. With the 
intense chemical energy obtainable from artificial sources, 
an efficient local bactericidal action certainly is secured 
in cases with tuberculous ulcers, sinuses, and certain other 
skin lesions. 

The effects of treatment should be controlled by a^-rays, 
as recommended by Eollier, for the local lesion is not yet 
completely healed when the clinical signs disappear. 

Pernicious Effects of Sunlight. — In conclusion it may 
be well to mention briefly a few evil effects which maj'^ 
arise from the injudicious use of sunlight. 

In patients with pyrexia very serious symptoms result 
if the dosage is not most carefully regulated, or, in some 
cases, if the treatment is proceeded with at all. The re- 
action caused by an initial exposure of the feet alone should 
be noted, and the further treatment adjusted accordingly. 
Acute infective lesions should not be exposed to the sun, 
as the local reaction would be too severe. 

I have stated already that over-exposure of the skin, 
before pigmentation has taken place, causes erythema. 
The skin of a small proportion of patients is so sensitive 
that it is undesirable to treat them with sunlight ; such 
patients may sometimes be rendered tolerant by exposure 
at first to diffuse light. 

Excessive stimulation of the optic nerve leads to nausea, 
giddiness and headache, and over-stimulation of the central 
nervous system is the cause of sunstroke. These effects 
should be prevented by adequate protection of the head and 
eyes. 

KEFERENCES. 

Finsen. Phototherapv. 

Snow. Therapeutics of Radiant Light and Heat. 

Cleaves. Light Energj. 

Rollier. Die Heliotherapie der Tuberkulose mit besonderer Beriiek- 

sichtigung ihrer chirurgischen Fornieu. 
Gauvain and De Voss. Brit. Journal of Tuberculosis. April, 1914. 
Gauvain. Brit. Journal of Tuberculosis. July, 1916, 



302 Index to Papers on the History of Medicine. 

Art. XVI. — An Index to the Papers on the History of 
Medicine that have been published in the Dublin 
Journal of Medical Science from its commencemeYit 
to August., 1916. By T. Percy C. Kirkpatrick M.D., 
M.K.I. A., Fellow and Eegistrar of the Eoyal College of 
Physicians of Ireland. 

The following Index is supplementary to the Index of 
Biographies that was published in the Journal of August, 
1916. In this index I have included not only the original 
papers dealing with the history of Medicine, but also 
many reviews of historical works. These reviews, in 
many instances, contain much additional information about 
the subject of the work under review. Again, I have to 
express my indebtedness to Mr. K. G. Phelps, Dun's 
Librarian, for the time and trouble he has expended on the 
formation of this index, and in the verification of the re- 
ferences. 

Anaesthetics. Anaesthetics. By George Foy. Vol. 86. 
1888. Pp. -281, 373, 485. Vol. 87. 1889. Pp. 116, 
225, 305, 486. 

Discovery of Modern Anaesthetics. By George 

Foy. Vol. 102. December, 1896. P. 488. 

Anatomy. Anatomical Knowledge and Original Dis- 
coveries of Irish Surgeons. By [Sir] Charles Cameron. 
Vol. 80. December, 1885. P. 453. 

Bologna, the part it has played in the History of 

Anatomy. By D. J. Cunningham. Vol. 86. December, 
1888. P. 465. 

History of Anatomy in Ireland. By A. Macalister. 

Vol. 77. January, 1884. P. 1. 

Athens. On the Plague of Athens as described by Thucy- 

dides. By Jonathan Osborne. Vol. 25. May, 1858. 

P. 309. 
Banks, [Sir] John Thomas. The Writ " de Lunatico In- 

(juirendo " in the case of Jonathan Swift, D.D. 

Vol. 31. February, 1861. P. 83. 
Barber Surgeons of Dublin. By Wm. D. Moore. Vol. 8. 

August, 1849. P. 232. 



By Dr. T. P. C. Kirkpatrick. 303 

Belcher, Thomas W. Notes on the Medianal Leper Hos- 
pitals of Ireland. Vol. 46. August, 1868. P. 36. 

Belfast. Early History of Belfast Medicine. By Robert 
Esler. Vol. 79. February, 1885. P. 158. 

Bicentenary of the School of Physic in Ireland. Vol. 134. 
August, 1912. P. 141. 

Boxwell, ^^"illia^n. Development of Therapeutic Immuni- 
sation. Vol. 134. December, 1912. P. 417. 

Boyle. Epitaph upon Godfrey Boyle, Alchymist. Vol. 6. 
November, 1848. P. 495. 

Byrne. Resolution on the death of J. A. Byrne. Vol. 91. 
April, 1891. P. 345. 

Cameron [Sir*] Charles. On the Anatomical Knowledge and 
Original Discoveries of Irish Surgeons. Vol. 80. 
December, 1885. P. 453. 

History of the College of Surgeons in Ireland. 

(Review.) Vol. 82. July, 1886. P. 37. Second 
Edition. (Review.) Vol. 141. June, 1916. P. 411. 

The Victorian Era, the Age of Sanitation. Vol. 

94. October, 1892. P. 289. 

Caton, Richard. I-Em-Hotep and Ancient Egyptian 
Medicine. (Review.) Vol. 119. May, 1905. P. 359. 

Celtic Medicine. By T. More Madden. Vol.108. Decem- 
ber, 1899. P. 430. 

Chemists of Ireland before the Year 1800. (Giving an 
Account of the Medico-Philosophical Society, 1756- 
1786.) Vol. 8. November, 1849. . P. 465. 

Children. Non-notifiable Infectious Diseases as a Cause 
of Mortality. By Sir John W. Moore. Vol. 133. May, 
1912. P. 355. 

Cholera. Sketch of the Origin and Progress of Asiatic 
Cholera. By R. J. Graves, 1st Series. Vol. 16. June, 
1840. P. 355. 

Clarke, James. Influenza. Vol. 131. March, 1911. P. 184. 

Clinical Case-taking. By Sir John W. Moore, Vol. 120. 
November, 1905. P. 392. 

Crawford, R. Last Days of Charles II. (Review.) Vol. 
129. May, 1910. P. 368. 

Creighton, C. History of Epidemics in Britain, Vol. II. 
(Review.) Vol. 100. December, 1895. P. 518. 



304 Index to Papers on the History of Medicme. 

Cunningham, D. J. Bologna, the Part it has played in the 
History of Anatomy. Vol. 86. December, 1888. P. 
465. 
Dalton, Eichard. Hospitals : their Origin and History. 

Vol. 109. January, 1900. P. 17. 
Diary of an Irish Medical Student, 1831-1837. Vol. 136. 

November, 1913. P. 360. 
Digitalis fuchsii. By John Knott. Vol. 124. November, 

1907. P. 393. 
Egypt. I-Em-Hotep and Ancient Egyptian Medicine. 
(Review.) A'ol. 119. May, 1905. P"! 359. 

Observations on the Medical Sciences in Egypt, 

Ancient and Modern. By R. J. Sargent. 1st Series, 
Vol. 20. September, 1842. P. 81. 
Esler, Robert. Early History of Medicine in Belfast. Vol. 
79. February, "^1885. P. 158. 

The Ulster Medical Society and its Presidents. 

Vol. 82. July, 1886. P. 75. 
Foot, A. W. Reminiscences of the Dublin Biological Club. 

Vol. 93. May, 1892. P. 425. 
Foy, George. Anesthetics. Vol. 86. 1888. Pp. 284, 373, 
485. Vol. 87. 1889. Pp. 116, 225, 305, 486. 

The Discovery of Modern Anaesthetics. Vol. 

102. December, 1896. P. 488. (Portrait of Sir 
Humphry Davy.) 
Gibson, G. A. Our debt to Ireland in the Study of the 

Circulation. Vol. 123. 1907. Pp. 241, 343, 401. 
Gore, Surg. -Gen. A. A. Connection of the Royal College 
of Surgeons in Ireland with the Army Medical Staff. 
Vol. 79. March, 1885. P. 254. 
Graves, R. J. Sketch of the Origin and Progress of 
Asiatic Cholera. 1st Series. Vol. 16. January, 1840. 
P. 355. 
Hare, H. A. Modern Treatment. (Review.) Vol. 132. 

August, 1911. P. 113. 
Hospitals. Ho.spitals : Their (h'igiu and History. By R. 
Dalton. Vol. 109. January. 1900. 1\ 17.' 

Infectious Hospital ( Dublin > Scheme. By [Sir] 

John W. Moore. Vol. 100. Decenil)er, 1895. P. 486. 



By Dr. T. P. C. Kirkpatrick. 305 

Hospitals. Leper Hospitals of Ireland. B. T. W. Belcher. 
Vol. 46. August, 1868. P. 36. 

Origin of some of the Dublin Hospitals. By T. 

Percy C. Kirkpatrick. Vol. 137. February, 1914. P. 
98. 

The Provincial Hospitals of Ireland. By Z. 

Johnson. Vol. 91. March, 1891. P. 217. 

Immunity. The Development of Therapeutic Immunisa- 
tion. By W. Boxwell. Vol. 134. December, 1912. 

P. 417. ^ 
Infectious Diseases. Compulsory Notification and Eegis- 

tration of Infectious Diseases. By [Sir] John W. 

Moore. Vol. 69. February, 1880. P. 96. 
Infectious Hospitals (Dublin) Scheme. By [Sir] John W. 

Moore. Vol. 100. December, 1895. P. 486. 
Influenza. By James F. Clarke. Vol. 130. March, 1911. 

P. 184. 
Jee, Sir B. S. A Short History of Aryan Medical Science. 

(Review.) Vol. 103. March, 1897. P. 228. 
Johnson, Z. The Provincial Hospitals of Ireland. VoL 

91. March, 1891. P. 217. 
Kirkpatrick, T. Percy C. Failure of the Vaccination Acts. 

Vol. 139. February, 1915. P. 81. 
History of the Prevention of Smallpox. Vol. 

129. May and June, 1910. Pp. 337, 410. 
Irish Medical Periodicals. Vol. 139. 1915. 

Pp. 268, 329, 428. Vol. 140. July, 1915. P. 1. 
Origin of Some of the Dublin Hospitals. Vol. 

137. February, 1914. P. 98. 
Knott, John. Aconite. Vol. 123. March, 1907. Pp. 

300, 375. 
Digitalis fuchsii. Vol. 124. November, 1907. 

P. 393. 
The Fatal Illness of Napoleon the Great. Vol. 

135. February, 1913. P. 119. 
The Mistletoe. Vol. 122. December, 1906. 

P. 457. 
Sir Walter Raleigh's " Royal Cordial." Vol. 



121. 1906. Pp. 63, 129. 



306 Index to Papers on the History of Medicine. 

Leper Hospitals of Ireland. By T. W. Belcher. Vol. 46. 

August, 1868. P. 36. 
Macalister, A. A Sketch of the History of Anatomy in. 

Ireland. Vol. 77. January, 1884. P. 1. 
M'Clintock, A. H. Else of the Dublin School of Mid- 
wifery. (Portrait of Sir Fielding Ould.) Vol. 25. 
February, 1858. P. 1. 

Madden, E. E. Some Notes on the Irish Mesmerists of 
the Seventeenth Century. (Greatrakes, Cook and 
Finaghty.) Vol. 4. August, 1847. P. 254. 

Madden, T. More. CeUic Medicine. Vol.108. December, 
1899. P. 430. 

On the recent Revival, under New Names, of 

Some Old Fallacies Bearing on Medicine. Vol. 90. 
July, 1890. P. 22. 

Mapother, E. D. Lessons from Lives of Irish Surgeons. 
(A. Mullen, Hans Sloane, Thomas Proby, Bartholo- 
mew Mosse, Sir F. Ould, Bryan Eobinson.) Vol. 56. 
November, 1873. P. 430. 

The Medical Profession in Ireland and its 

Work. Vol. 82. September, 1886. P. 177. 

Medical Certificates. Exploitation of the Medical Pro- 
fession in respect of Medical Certificates. By Sir 
John W. Moore. Vol. 139. May, 1915. P. 338. 

Medical Education and Examinations in 1887. By [Sir] 
John W. Moore. Vol. 85. January, 1888. P. 36. 

Medicine in Ireland, A Sketch of the History of. By T. 
G. Moorhead. Vol. 126. December, 1908. P. 417. 

Midwifery, Eise of the Dublin School of Midwifery. By 
A. H. McClintock. With portrait of Sir Fielding 
Ould. Vol. 25. February, 1858. P. 1. 

Moore, Sir John W. Clinical Case-taking. Vol. 120. 
November, 1905. P. 392. 

The Compulsory Notification and Eegistration 

of Infections Diseases. Vol. 69. February, 1880. P. 
96. 

Exploiiation of the Mechcal Profession in re- 

pect to Medical Ccrlificates. Vol. 139. Mav, 1915. 
P. 338. 



By Dr. T. P. C. Kirkpatrick. 307 

Moore, Sir John W. The Infectious Hospitals (Dubhn) 

Scheme. Vol. 100. December, 1895. P. 486. 
: Medical Education and Examinations in 1887. 

Vol. 85. January, 1888. P. 36. 
Non-notifiable Infectious Diseases as a cause 

of Mortality in Childhood. Vol. 133. May, 1913. P. 

355. 
Notification of Tuberculosis in Ireland : Its 

Failure. Vol. 137. May, 1914. P. 331. 
The Present and the Future of State Medicine. 

Vol. 83. March, 1887. P. 235. 
The Present Epidemic of Scarlet Fever in 

Dublin. 1884. Vol. 77. April, 1884. P. 364. 
Sanitary Organisation in Ireland in its present 



Medical Aspect. Vol. 79. March, 1885. P. 197. 
Some Public Health Problems in Ireland. Vol. 

117. March, 1904. P. 178. 
Why has Smallpox declined in Prevalence and 

Fatality? Vol. 130. August, 1910. P. 106. 
Moore, William D. Extracts from the Eecords of the 

Barber Surgeons of Dublin. A^ol. 8. August, 1849. 

P. 232. 
An Outline of the History of Pharmacy in 

Ireland. Vol. 6. August, 1848. P. 64. 
Moorhead, T. G. A Sketch of the History of Medicine in 

Ireland. Vol. 126. December, 1908. P. 417. 
Report on Opsonins. A'ol. 124. October, 1907. 

P. 284. 
O'Brien, W. P. The Great Famine in Ireland. (Review.) 

Vol. 102. August, 1896. P. 128. 
Ophthalmic Surgery in Vienna. By Sir W. E. Wilde. 

1st Series. Vol. 20. November, 1842. P. 254. 
Opsonins, Report on. By T. G. Moorhead. Vol. 124. 

October, 1907. P. 284. 
Osborne, Jonathan. On the Plague of x\thens as 

described by Thucydides. Vol. 25. Mav, 1858. P. 

309. 
JVttigrew, T. J. Medical Portrait Gallery. (Review.) 

1st Series. A'ol. 16. September, 1839. P. 108. 



308 Index to Papers on the History of Medicine. 

Pharmacy in Ireland. By William D. Moore. Vol. 6. 

August, 1848. P. 64. 
Physicians. History of the College of Physicians of Ire- 
land. By Aquilla Smith. 1st Series. Vol. 19. March, 

1841. P. 81. 
Plarr, Victor G. The Catalogue of the Koyal College of 

Surgeons of England. Vol. 130. November, 1910. 

P. 352. 
Pompeii. Surgical Instruments of Pompeii and Hercu- 

laneum. Vol. 14. August, 1852. P. 130. 
Public Health. The Present and the Future of State 

Medicine. By [Sir] John W. Moore. Vol. 83. March, 

1887. P. 235. 
Sanitary Organisation in Ireland in its present 

Medical Aspect. By [Sir] John W. Moore. Vol. 79. 

March, 1885. P. 197. 
Some Public Health Problems in Ireland. 



By Sir John W. Moore. Vol. 117. March, 1904. P. 

178. 
Purdon, Henrj- S. Notes on Old Native Eemedies. Vol. 

100. 1895. Pp. 214 and 293. 
Old Irish " Herbal " Skin Remedies. Vol. 

106. July, 1898. P. 27. 
Randolph, J. Memoir on the Life and Character of Philip 

Syng Physick, M.D. (Review.) Vol.20. November, 

1841. P. 303. 
Ringland, Dr. A Brief History of the Epidemic Smallpox 

which visited Dublin in the Autumn and Winter of 

1830-40. 1st Series. Vol. 19. P. 429. 
Salmuth Heinrich. A Specimen of Seventeenth Century 

Physiology and Medical Jurisprudence. Translated 

by Henry King. Vol. 78. 1884. Pp. 332, 402. 
Sanitary Organisation in Ireland in its present Medical 

Aspect. By [Sir] John W. Moore. Vol. 79. March, 

l.SHo. V. 197. 
Sanitation. The Victorian Era, the Age of Sanitation. By 

Sir C. A. Cameron. Vol. 94. October, 1892. P. 289. 
Sargent, R. J. Observations on the Medical Sciences in 



By Dr. T. P. C. Kirkpatrick. 309 

Egypt, Ancient and Modern. 1st Series. Vol. 20. 

September, 1842. P. 81. 
Scarlet Fever. Present Epidemic of Scarlet Fever in 

Dublin. By [Sir] John W. Moore. Vol. 77. April, 

1884. P. 364. 
Seaman, L. L. The Eeal Triumph of Japan. The Con- 
quest of the Silent Foe. (Review.) Vol. 123. 

January, 1907. P. 2-5. 
Smallpox. History of the Prevention of Smallpox. By 

T. P. C. Kirkpatrick. Vol. 129. 1910. Pp. 337, 410. 

Why has Smallpox Declined in Prevalence and 

Fatality? By Sir John W. Moore. Vol.130. August, 
1910. P. 106. 

Epidemic in Dublin, 1839-40. By Dr. Ringland. 1st 

Series. Vol. 19. P. 429. 

Smith, Aquilla. Contributions to the History of Medicine. 
1st Series. Vol. 17. May, 1840. P. 2io. 

A History of the College of Physicians of 

Ireland. 1st Series. Vol. 19. March, 1841. P. 81. 

South, John F. Memorials of the Craft of Surgery in 
England. (Review.) Vol. 82. November, 1886. P. 
374. 

Spaight, H. W. Therapeutics in the Eighteenth Century. 
Vol. 109. April, 1900. P. 302. 

Stokes, Sir William. AVork done in Surgery by its Pro- 
fessors in the Royal College of Surgeons in Ireland. 
Vol. 84. November, 1887. P. 353. 

Stubbs, W. J. History of the University of Dublin (Re- 
view.) Vol. 89. April, 1890. P. 317. 

Sullivan, W. K. Irish Chemists before the year 1800. 
Vol. 8. November, 1849. P. 465. 

Surgery. Craft of Surgery in England. (Review.) Vol. 
82. November, 1886."^ P. 374. 

Historical Sketch of Surgery. (Review.) Vol. 90. 

October, 1890. P. 319. 

Work done in Surgery by the Professors of the 

Royal College of Surgeons in Ireland. By Sir W. 
Stokes. Vol. 84. November, 1887. P. 130. 



310 Index to Papers on the History of Medicine. 

Surgical Instruments of Pompeii and Herculaneum. (Re- 
view.) Vol. 14. August, 1852. P. 130. 
Swift. Borne Particulars respecting Swift and Stella, 

with engravings of their Crania. By Sir W. R. Wilde. 

Vol. 3. May, 1847. P. 384. Vol. 4. August, 1847. 

P. 1. 
The Writ ' ' de Lunatico Inquirendo ' ' in the 

case of Jonathan Swift. By [Sir] J. T. Banks. Vol. 

31. February, 1861. P. 85. 
Therapeutics in the Eighteenth Century. By H. W. 

Spaight. Vol. 109. April, 1900. P. 302. 
Trinity College^ Dublin, Bicentenary of the School of 

Physic in Ireland. Vol. 134. August, 1912. P. 141. 
Tuberculosis. Notification of Tuberculosis in Ireland : Its 

Failure. By Sir John W. Moore. Vol. .137. May, 

1914! P. 331. 
Vaccination. Failure of the Vaccination Acts. By T. 

Percy C. Kirkpatrick. Vol. 139. February, 1915. P. 

81. 
Vienna. Ophthalmic Surgery in Vienna. By Sir William 

R. Wilde. Vol. 20. November, 1841. P. 254. 
Watson, B. A. Historical Sketch of Surgery (Review.) 

Vol. 90. October, 1890. P. 319. 
Wilde, Sir William R. A Short Account of the School of 

Ophthalmic Surgery in Vienna. Vol. 20. November, 

1841. P. 254. 
Some Particulars respecting Swift and Stella. 

Vol. 3. Mav. 1847. P. 384. Vol. 4. August, 1847. 

P. 1. 
Williams, C. J. B. (President of the New Sydenham 

Society). Memoirs of Life and Work. (Review.) 

Vol. 78. August, 1884. P. 138. 
Withington, E. T. Medical History from the Earliest 

Times (Review.) Vol. 98. November, 1894. P. 411. 
Ybarra, A. M. Fernandez de. Medical History of Chris- 
topher Columbus. Vol. 98. 1894. Pp. 166, 242. 
Young, Andrew K. Professional Reminiscences. Vol. 87. 

June, 1889. P. 499. 
Young, Norwood, Napoleon in Exile. (Review.) Vol. 

110. September, 1915. P. 192. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



The Story of a Red Cross Unit in Serbia. By James 
Beery, B.S., F.K.C.S. ; F. May Dickinson Berry, 
M.D., B.S.; W. Lyon Blease, LL.M., and other 
Members of the Unit. London : J. & A. Churchill. 
1916. Demy 8vo. Pp. xvi + 293. 

The raison d'etre of this entertaining and instructive book 
is so well stated by the publishers that we think it well to 
give their description of it in full. It is the story of how 
a Voluntary Hospital Unit came into existence, and of 
the doings and experiences of its members during a year's 
stay in Serbia. The writers tell of the struggle with 
typhus, of the introduction of sanitary reforms into most 
insanitary surroundings ; they touch upon Serbian history 
and politics, describe Serbian officials and the Serbian 
people, Austrian prisoners and Austrian captors, for during 
the last three months the Unit was in the hands of the 
Austro-Hungarians. Various amusing episodes are re- 
counted in connection with both the Serbians and the 
Austrians. The book is full of sympathy for the unfor- 
tunate Serbian nation. 

With the exception of two chapters, VI. and X., which 
have been contributed by Dr. Helen Boyle and Lieutenant 
Donald C. Norris, K.A.M.C, the work has been written 
by Mr. James Berry, B.S., F.E.G.S., Senior Surgeon, 
and his wife, Dr. F. May Dickinson Berry, M.D., B.S., 
Anaesthetist and Physician , Heads of the Unit ; and by 
Mr. Walter Lyon Blease, "Gentleman Orderly" to the 
Unit. 

Considering the number of authors, the way in which 
the work has been blended into a harmonious whole is 



312 Reviews and Bibliographical Notices. " 

marvellous, anH speaks well for the literary powers of the 
■several authors and for the skill of the Editors-in-chief, 
Mr. and Mrs. Berry. 

The seed out of which the ' ' Unit ' ' grew was planted 
at a meeting held in aid of Serbia at the Stein way Hall, 
London, in December, 1914. That meeting was attended 
by Mr. and Mrs. Berry, and it was owing to their energy 
and resource that the Mission took its origin. Both these 
able and indefatigable workers are on the staff of the Eoyal 
Free Hospital, London, and so the Mission was known, 
not only as the " Anglo-Serbian Hospital Unit," but also 
very generally as the " Eoyal Free Hospital Unit," al- 
though the Hospital Board did not see their way to allow 
the Mission to use the latter name. In Serbia it was 
universally known as the " Berry Mission," and indeed 
little wonder, having regard to the extraordinary ability 
with which the ' ' Heads of the Unit ' ' appear to have con- 
ducted the Mission from start to finish. 

To the medical reader of this entertaining book the 
account, in Chapter V., of a great epidemic of typhus fever 
and its cause, and how it was successfully dealt with, will 
prove of extreme interest. 

Typhus had occurred in the previous Balkan War two 
years before (1913), but had never attained anything like 
the magnitude of the outbreak of 1915. Whether or not 
the disease on this latter occasion was originally introduced 
by Austrian ])risoners — as was commonly asserted — there 
can be no doubt that its widespread occun-ence throughout 
Serbia was due to the soldiers, both wounded and un- 
wounded, Serb and Austrian, who were at the time dis- 
tributed in hospitals, in other public buildings, and in 
private houses all over the country. 

On February 11, 1915, the Anglo-Serbian Red Cross Unit 
arrived at Vrnjatchka Banja — a watering-place with warm 
sulphur springs — before the war one of the most fashion- 
able and important health resorts in Serbia. The term 
means the Baths of Vrntse — a small town or village lying 
some 30 miles east-south-east from a range of hills near 



Berry, &c. — .4 Red Cross Unit in Serbia. 313 

€hachak, on which hills the Austrians had been decisively 
defeated by the Serbians in a bloody battle some time pre- 
viously. After the battle hundreds of wounded were 
poured into Vrntse, where there was no hospital, and 
where only scanty accommodation of any kind was avail- 
able. 

A few days before the arrival of the Eed Cross Unit 
typhus had broken out. The disease had been introduced 
and spread by patients who were being sent into the town 
in batches at short notice, and without any information 
as to what was the matter with them. Many of these 
patients brought typhus, either declared or in the incuba- 
tion stage. Patients and hospitals — the latter extem- 
porised in hotels and boarding-houses — swarmed with lice, 
and the disease spread rapidly. The members of the Unit 
on their arrival were told that of sixty-eight patients who 
had recently come to the town, fifty had died within a 
fortnight. 

Here is the account given by Mr. Berry : — " The hos- 
pitals were in a most unsatisfactory condition ; there were 
practically no nurses ; what nursing there was, was done 
by untrained Austrian prisoners. The windows were 
always closed, and the heat and stench were almost un- 
bearable. Little or no attempt was made to wash the 
patients, or to provide them with clean linen. The treat- 
ment consisted chiefly in the administration of powders 
(antipyrin, salicylates, &c.), by orderlies at frequent in- 
tervals. The diet was mainly of bread and thin soup. 
Under the pillows would be found the remains of the daily 
rations of bread, and often an accumulation of pills or 
powders, for they were generally just handed round, the 
patient being left to take them or not as he felt inclined. 
There was at this time no public laundry, nor public dis- 
infection of any kind, and the clothes of the patients were 
rarely if ever disinfected in the hospitals themselves." 
(Page 44.) Mr. Berry adds : " It was very evident from 
the state of things in Vrntse that very favourable con- 
ditions existed for the spread of typhus, and that, unless 



314 Reviews and Bibliographical Notices. 

some stringent measures were taken, the whole plac& 
would be overrun by the epidemic." (Page 45.) 

Stringent measures were, happily, soon taken, and with 
conspicuous success, by the Anglo-Serbian (Berry) Red 
Cross Unit in collaboration with the British Red Cross 
Unit, which arrived on February 15th, with Captain 
Bennett as its non-medical head. 

On March 1st a conference was held at the Terapia, a 
hydropathic establishment, which was taken to be the 
principal hospital of the Anglo- Serbian Red Cross Unit. 
The medical staff of both Missions and Captain Bennett 
took part in the conference, at which it was decided, on 
the suggestion of Dr. Ernest U. Williams, radiographer 
and physician to the Anglo-Serbian Mission, to adapt and 
use one of the hot springs for washing patients, and to 
transform the " Drzhavna Kafana " (National, or 
" State," Coffee-house), which stood close by the Terapia, 
into a receiving" or clearing hospital. Patients who de- 
veloped typhus were drafted into the infectious 
"/baraques." It was not practicable to keep patients in 
the clearing hospital during the whole possible time of 
incubation, but, even if the patient fell ill of typhus after 
being sent to another hospital, there was little or no chance 
of his trans)nHti7ig the infection, if he were free from lice. 
It was arranged that the baths and ' ' Drzhavna ' ' should 
be run jointly by both Missions. 

Finding that the existing accommodation would not 
suffice for all the typhus cases with which the Anglo-Ser- 
bian Mission would have to deal, Mr. Berry and his 
medical staff had a substantial ' ' baraque ' ' erected in the 
remarkably sbort space of fourteen days, at a total cost of 
about 5,000 dinars (£150). It was ready for the reception 
of 50 patients on March 29th, but the Mission did not find 
it necessary to o[)en it until several days' later. All 
patients who entered its portals were stripped, shaved, and 
treated to a warm bath l)efore being taken to the ward, 
their clothing being" immediately removed in closed sacks 
for disinfection elsewhere. Mr. Berry remarks, with 



Berry, &c. — A Red Cross Unit in Serbia. 315 

pardonable pride, " We believe it to be a fact that outside 
the bathroom only one louse was ever seen in our baraque. 
After a short time we used to offer 100 dinars to any visitor 
who could discover a louse, but the reward was never 
claimed ! ' ' (Page 55 . ) • 

From the beginning, the medical members of the Mis- 
sion recognised that the key of the position as regards the 
typhus epidemic was the elimination of its carrier — the 
louse. Hence the elaborate precautious as to washing and 
disinfection which were instituted. The keen eyes of the 
watchful nurses at the Terapia Hospital discovered, in 
one or two cases, a few days after admission, a louse or 
two, which had hatched out from nits adhering to body 
hairs. This led to the more thorough process of shaving 
every hair from all parts of the body. The hair was re- 
moved not only from head, face, armpits, and pubes, 
but also from the thighs, legs, chest and abdomen. 

Mr. Berry states that although when his party 
first arrived in Serbia, most of the members had 
had but little practical experience of a disease so 
rare in England as typhus fever is,- yet their own 
observations, after a comparatively short time, sufficed 
to impress upon them the truth of the view that 
the disease was transmitted by means of the body louse. 
At the same time, it must be remembered that it 
is not every louse, but only the louse which has become 
infected from a typhus patient, that acts as a carrier of the 
disease. The Mission claims, with equal confidence, to 
have proved that the flea does not in Serbia carry typhus. 
" The case against the flea was never strong," writes Mr. 
Berry, " but our experience seems to have demolished it 
altogether." (Page 60.) 

" With regard to the treatment of typhus, no drug that 
we knew of seemed to have any appreciable influence upon 
the course of the disease. ... On the other hand, 
the application of the ordinary general principles of 
hygiene, diet, and especially nursing, seemed to us to be 
extremely valuable elements in the treatment. We have 



316 Reviews and Bibliographical Notices. 

but little doubt that many of our patients, some of whom 
were desperately ill, owed their lives to the devoted nursing 
of our skilled sisters no less than to the careful watchful- 
ness of our doctors." (Page 60.) 

An incident of questionable taste in connection with the 
crusade against lice is recorded at page 70. Dr. Williams 
" struck up a little composition, set to a well-known tune." 
We will not quote this "little comj)osition." Suf&ce it 
to say that ' ' at this point there entered a Serbian gentle- 
man, who, recognising the tune, asked, in French, if that 
was our National Anthem ; and w^e replied that it was." 

Mr. Berry, or, as he was usually called, "the Pro- 
fessor," knowing Serbia better than most of the English 
(? British) who went out with hospitals, determined from 
the first that he would help the bureaucracy in the efforts 
which they were making to overcome the prevailing in- 
difference to the rules of Public Health. Side by side 
with the hospital work of the Mission went the work of 
sanitary reform. Chapter XL contains an account of the 
more important of the enterprises undertaken by the 
Mission with this end in view. There can be no doubt 
that the sojourn of the Anglo-Serbian Ked Cross Unit at 
Vrntse, from February 11, 1915, to February 16, 1916 — 
a little more than a year — must have paved the way for 
an improved system of Public Health in a country which 
is too little known in Western Europe. The Mission left 
Serbia "with a warm feeling of respect and affection for the 
simple, kind-hearted and generous Serbian people, whose 
history is so full of glorious deeds that it deserves to be 
better known in this country, and whose struggles for free- 
dom and emancipation from oppression have been so 
heroic." 

In fairness, we would like also to quote Mr. Berry's 
statement (page 288) that " Hungary, in her attitude to 
the British Missions, was a chivalrous foe, and Hungary 
iln the j)ast viewed England and English institutions with 
admiration and affection." 

This "Storv of a Red Ooss Unit in Serbia" is illustrated 



Gray — Anatomy, Descriptive and Applied. 317 

by 28 photographic views, and by a map of the country 
and a portrait of the Crown Prince of Serbia. To him the 
work is dedicated, by permission, in the following terms : 
" To H. E. H. Alexander, Crown Prince of Serbia, who, 
by his military skill, his energy, and his ability, has done 
so much for his country and for the cause of the Allies." 

J. W. M. 

Anatomy, Descriptive and Applied. By Henry Gray, 
F.R.S. Nineteenth Edition. Edited by Professor 
Egbert Howden,M.A., Sc.D.,M.B.,Prof. of Anatomy 
in the University of Durham. Notes on Applied 
Anatomy revised by A. J. Jex-Blake, M.A., M.D., 
F.E.C.P., and W. Fedde Fedden, M.B., M.S., 
F.E.C.S. London : Longmans, Green & Co. 1916. 

Gray's Anatomy, first pubhshed in 1858, has now reached 
its nineteenth edition, and we may say at once that the 
latest edition is in every way a worthy successor of those 
which hav^ gone before and made the reputation of the 
famous text-book. It is pleasant to find that but very 
few alterations in the plan of the work have been intro- 
duced, and that the very excellent arrangement of the 
later editions has been adhered to. Some new illustra- 
tions have been inserted, and a few of the older figures 
have been improved by the addition of colour. The 
sections dealing with microscopic structure have been re- 
vised and made more useful by the inclusion of several 
beautiful coloured drawings. The text has not been 
increased in volume to any appreciable extent, and, by 
the omission of the glossary of the Basle anatomical 
nomenclature, the actual size of the nineteenth edition 
has been reduced below that of the eighteenth. All the 
terms used in the text are either those suggested by the 
Basle Committee or are their direct English translations. 
No more useful text-book of anatomy could be placed 
in the hands of a student of Medicine, and we congratulate 
the distinguished editor and his colleagues upon the 
success of their work. 



318 Reviews and Bibliographical Notices. 

Ninth Annual Report of the Trustees of Massachusetts 
Hospitals for Consumptives. November 30, 1915. 
Boston : Wright & Potter Printing Co. 1916. Demy 
8vo. Pp. 128. 

The Massachusetts Sanatoriums are four in number — 
Reading, Lakeville, Westfield, and Rutland — accommodat- 
ing about 1,000 patients. The objective of the trustees is 
the arrest of early and favourable cases of pulmonary tuber- 
culosis. This ideal, however, can be attained only when 
the city hospitals of the Commonwealth have enough beds 
for the treatment of tuberculosis cases. As it is, the ad- 
mission of advanced cases of the disease are admitted 
principally for the protection of the public. The admission 
of such cases involved the risk of sepsis, which entailed 
the utmost vigilance to avoid. Nine years' experience 
has, however, not been lost on municipal authorities ; the 
hospital beds for tubercular cases have been increased from 
330 in 1911 to 1,120 in 1915, and it is now felt that more 
discrimination in the selection of cases for admission to 
the sanatoriums is desirable, as manifestly incurable cases 
seriously diminish the chances of recovery in incipient 
cases, and deprive the dying of home associations in their 
last days of life. That the public recognise the benefits of 
the sanatoriums is shown by the distressingly long " wait- 
ing list," which includes 1,600 names. Long as the list 
is, it is a healthy sign of the recognition of the value of 
^skilled treatment and hygienic surroundings, and is not 
due to an increased morbidity. 

One of the most imjiortant ]iroblems for the Common- 
wealth authorities is the providing suitable employment 
for discharged patients. As far as possible, they are em- 
ployed on work in connection with the sanatoriums, and 
whilst so engaged are kept under |ir()]ier medical super- 
vision. Unfortunately this scheme has its drawbacks — 
employees perfectly well able to work may still have tuber- 
culous sputum, and should not be segregated with non- 
tiiberculous workmen. I'lihlic opinion has during the year 
been inniienced in lavoui- of the sanatori'iinis l)\' ninueroiis 



Report of Massachusetts Hospitals for Consumptives. 319 

tracts contributed by members of the medical staff. His 
Excellency the Governor of the Commonwealth gave a 
grant of .£1,000, and the labour of a numerous body of 
prisoners, v^ho v^^ere fed and lodged in aphack, to clear 
up waste and swamp land. The experiment was a great 
success, the land being brought to a high state of cultiva- 
tion. Of the work performed by patients, we find 180 
hours were employed in painting screens, 50 hours in 
mending chairs, 282 hours in preparing garden tracks, 
31,902 hours in household work. During the year in the 
Eeading Sanatorium, 78 tablecloths, 482 towels, 172 
laundry bags, 2 pairs sash curtains, 6 laboratory aprons, 
3 laparotomy sheets, 13 binders, 72 pillow-slips, and 55 
pillow-covers were made. Farming operations during 
1915 produced an income of .£4,008. Poultry rearing 
resulted in getting 5,236 dozen of eggs, 4f tons of poultry, 
and in the sale of 680 ]3ullets. 

An appeal is made for the establishment of a dairy at the 
sanatoriums ; plainly in the U.S.A., as here, the standard 
of morality of milk-vendors is low. The medical reports are 
brief. Of the Eutland we read : — "No new^ method of treat- 
ment, no new detail of any old method of sufficient interest 
to rehearse has been tried during the year." The Westfield 
Sanatorium admitted during the year 328 patients, "of 
which 25 per cent, were incipient cases ; all but 12 of these 
were children." To Lakeville 457 patients were admitted. 
The medical report states that ' ' less and less medical treat- 
ment is used each year, and always as little as possible. 
The only departure . . . has been the use of tuberculin 
in a few selected cases." The North Eeading medical 
report is much fuller. We read that " 60 per cent, of 
the patients treated required symptomatic remedies for 
their relief and comforts. Five patients were treated wdth 
artificial pneumothorax." From this treatment one 
case of haemorrhage derived much benefit ; and another 
patient suffered a severe pleural shock following his fourth 
treatment. In two cases of empyema, paracentesis was 
tried ineffectuallv. The mana""ement of these sanatoriums 



320 Reviews and Bibliographical Notices. 

is so excellent that we have given more space than usual 
to its details ; for now that the public are showing some 
interest in hygienic medicine, some good may result to ua 
from the story of the thoroughness of our Massachusetts, 
brethren in this matter. 



Influence of Joy. By George Van Ness Dearborn, 
Instructor in Psychology and in Education, Sargent 
Normal School, Cambridge ; Psychologist and Physio- 
logist to the Forsyth Dental Infirmary for Children^ 
Boston ; &c. Mind and Health Series. Edited by H. 
Addington Bruce, A.M. London : William Heine- 
mann. 1916. Cr. 8vo. Pp. xviii-i-2-23. 

We have a pleasant recollection of reviewing some other 
works in connection with this excellent series of hand- 
books, which has been designed to extend a knowledge of 
the more recent discoveries in connection with the subject 
of psychological research. For this reason we anticipated 
that a considerable amount of pleasure would be derived 
from a study of " The Influence of Joy," and in this — we 
may at once state — disappointment has not been our lot. 

The enormous effect that the mind has upon the physical 
state has long since been recognised. By those who suffer 
from dyspepsia and allied abdominal conditions, this fact is 
especially appreciable; nor can we wonder at this, know- 
ing as we do that even slight psychic disturbances have 
been shown to have a distinct effect on peristalsis. 
Similarly, we can trace the deleterious effects of worry 
and its associates upon the organism in general. 

The affective tone of an emotion — its pleasantness or 
unpleasantness — is of supreme importance to the in- 
dividual. 

To almost all beings in a normal state of health, the 
former is a goal sought for eagerly, and frequently to its 
maximum of satisfaction. 

The state of mind so occasioned — the constant strivinsf 



Walker — An Introduction to Dermatology 321 

after happiness — leads to a universal stimulation which 
has a practical bearing in life. 

Through it we obtain a mental and physical activity in- 
volving a large degree of energy-expenditure as compared 
with the limitation of movement and other depressing 
effects common to most emotions of an unpleasant nature. 

Professor Dearborn helps us to understand life and the 
means by which we may derive most good therefrom. He 
pleads for the abolition of the depressing in the education 
of the child, and places an intense value upon happiness, 
associated as it is with an increased productiveness of 
material in all departments of toil. 

In his own w^ords, " Not always is the race to the swift, 

or the battle to the strong; often, very often indeed, one 

inclines to think that both go to the happy — lords of the 

world." 

H. E. C. E. 

A71 Introduction to Dermatology. By Norman Walker, 
M.D., F.E.C.P., Physician; with the assistance of E. 
Cranston Low, M.B., F.E.C.P., Assistant Physician 
for Diseases of the Skin, the Eoyal Infirmary, Edin- 
burgh. Sixth Edition. With 63 coloured Plates and 
89 Illustrations. Edinburgh and London : William 
Green & Son, Limited. 1916. Demy 8vo. Pp. 
xviii + 363. 

The first edition of Dr. Norman Walker's " Introduction 
to Dermatology " was published in 1899. Its subsequent 
history has been one of uninterrupted and unqualified 
success. It is somewhat amusing to read in what is styled 

An Introduction to Dermatology ' ' the following sen- 
tence (page 170) : " The disease [psoriasis] requires 
little description ; everyone is familiar with the dry silvery 
scales on the red circular patches and rings of psoriasis." 

There are two or three outstanding features in the pre- 
sent, the sixth, edition of a standard, nay a classical work. 
Of these features the first is the richness and number of 
the illustrations. 

2 A 



322 Reviews and Bihliograpliical Notices. 

The fifth edition was published in February, 1911 ; the 
present edition is dated August, 1916. In the former 
there were 43 coloured plates and 79 illustrations in the 
text ; the latter contains 63 coloured plates and 89 illustra- 
tions in the text. Several of the coloured plates in the 
fifth edition were taken from casts by Dr. Cranston Low — 
whose name now for the first time appears on the title 
page — or by Miss Rae. Nearly all the new illustrations in 
the sixth edition w^ere the handiwork of this talented lady- 
artist, to whom Dr. Walker expresses his acknowledg- 
ments for them as w^ell as for her proof-reading and 
indexing. One of the new illustrations involved a journey 
to Norway. It is reproduced from a cast of a typical case 
of nodular leprosy, kindly given to the author by Dr. Lie, 
of Bergen. The plate faces page 305, and on page 306 
Figure 73 illustrates the same terrible disease. It is from 
a photograph given to the author by Dr. Hansen, who 
discovered the Bacillus leprae in the year 1884. 

The other novelty in this edition is the article by Dr. 
Cranston Low on Pellagra, illustrated by three casts in 
coloured plates, after the fashion of the life-like wax- 
models by M. Baretta, in the Museum of the Saint Louis 
Hospital, Paris. These beautiful works of art were re- 
I^roduced in 2:>hoto-lithochromes in " A Pictorial Atlas of 
Skin Diseases and Syphilitic x\ffections," edited and an- 
notated by Dr. J. J. Pringle, of the Middlesex Hospital, 
London, and published in 1897 by the Eebman Publishing 
Company and the \Y. B. Saunders Company, Phila- 
delphia. 

It is not often that a physician or surgeon remembers 
to thank the nurses, to whom he owes so much in his 
j)ractice. Dr. Norman Walker does not forget to exjiress 
his indebtedness " to Sister Watt for the care with which 
all my therajieutic experiments were carried out, as well 
as for many shrewd observations of their effects." 

One of the most interesting sections in the work is that 
on " Dermatitis Venenata," illustrated by beautiful pic- 
tures of Rhus toxicodendron and Primula obconica. Dr. 



Auicriccni Cijitccological Society. 323 

Stewart Macdoughall, Steven Lecturer in the University 
of Edinburgh, answered numerous queries addressed to 
him by the author about these and other poisonous plants. 

Lastly, a notable feature in this edition is the all but 
complete disappearance of the word " Eczema " from jts 
pages. Dr. Walker writes in the Preface : " To the older 
school the attempt to jettison eczema will seem almost 
sacrilegious, but I am convinced that the fewer cases 
students are taught to call ' eczema ' the better it will be 
for their patients." 

' ' By using in its stead the word dermatitis (without any 
adjective), we admit our ignorance, and constantly remind 
ourselves of the necessity of searching out the cause of the 
inflammation." (Page 95.) 

We look upon this " Introduction to Dermatology " as 
the best of the modern British or American W^orks on Skin 
Diseases. The published price is fifteen shillings net, but 
it is well worth the money, although the sum is rather 
large for a medical student's purse. 

Transactions of the American Gyyiecological Society. 
Vol. XL. For the year 1915. Philadelphia : Wm. J. 
Dornan. 1915. 

The importance of the Transactions before us is so great 
that we feel we must pause and consider the Transactions 
of our Academy here. Truly, they are valuable, but it 
is easy to imagine how that value could be enhanced if 
more interest were taken in the Academy. The birth of 
the medical clubs was a social event ; we are not decrying 
their scientific worth, which is distinctly local. To justify 
its existence, a medical society should publish Transactions. 
In order to keep Ireland, and more particularly Dublin, 
in the forefront of scientific Medicine the Irish doctors 
must produce more good works which should be read at 
the sectional meetings of the Academy, and which would 
be published in the Transactions which are sent through- 
out the medical world. 

All the papers which were read last year at the meet- 
ings of the American Gyna'cological Society are worthy 



324 Reviews and Bibliographical Notices. 

of note. Some have appeared in " Surgery, Gynfecology 
and Obstetrics." Ovaries' figure largely as a subject for 
essay, and there are two excellent papers on the value 
of ovarian transplantation. We are surprised to find that 
such a clever gynaecologist as Vineberg, in a paper on the 
fate of the ovaries after hysterectomy, advocates their 
removal with the uterus. In our experience, the woman 
whom w^e can inform of the conservatism of the ovaries 
is happier and has a more natural life than the woman in 
whom it has been necessary to perform total extirpation 
of uterus and ovaries. One of the most valuable of the 
many useful parts of the book is the discussion on pro- 
lapsus uteri — a discussion in which many leading gynae- 
cologists took part, and in which most of the modern 
methods of treatment were discussed. The relationship 
betw^een gyuEecology and neurology is fully treated, and 
the opinions of psychologists and gynecologists are found. 
One of the most difficult problems which confronts the 
gynaecologist is when it is necessary to determine in a 
neurotic patient with a definite gynaecological lesion, the 
extent to which the latter depends on the former condition. 
We have not space at our disposal to deal with all the 
papers in these Transactions of the American Gyna?co- 
logical Society — a society to which the greatest commenda- 
tion is due for its latest volume, which more than equals 
the high standard set by its predecessors. 

Post-Mortem Examinations. By William S. Wads- 
worth, M.D., Coroner's Physician of Philadelphia. 
Philadelphia : W. B. Saunders Company. 1916. 8vo. 
Pp. 598. Illustrations, 304. 

The introduction to this work is so full of worthy senti- 
ments that one expects great things from what follows. 
The making of post-mortem examinations is an art, to be 
master of which demands a thorough knowledge of human 
nature and a working knowledge of every other branch of 
science. This is no narrow subject, like medicine or 
surgery or pathology, but an all-embracing study, which 
iiK-ludcs all these, and much more besides. According to 



Wadsworth — Post-Mortem Examinations. 325 

Dr. ^Yadsworth, all previous presentations of this subject 
have made it but a small and quite subsidiary part of either 
pathology or anatomy, and, consequently, such presenta- 
tions have been made to suit the narrow view of either 
pathologist or anatomist. 

Surely, Dr. Wadsworth must have suffered at the hands 
of the medical profession. Indeed, one suspects that the 
writing of this book is something in the nature of a " re- 
prisal," and his method is a simple one. 

He sets up a series of lay figures — or shall we call them 
" Aunt Sallies "? — and exhausts a not over-refined wit in 
wordy assaults on his victims. His "physicians" are 
merely idiots, unless a little self-assertive, when they 
become " clinical hogs." His surgeons, callous homi- 
cides. Xeurologists are vicious and dishonest ; patholo- 
gists either "fussy housemaids" or narrow-minded 
maniacs. 

His assistants may be " cubs," and in a particularly 
offensive passage a fatuous mental attitude is referred to 
as ' ' savoring more of the menstruating sex than of true 
science." The only tribe for whom he has a good word 
js that of his friends the undertakers. 

When not merely abusive. Dr. Wadsworth is voluble 
and long-winded. His moralising is like the oratory of a 
famous historian : ' ' When he speaks in public he is like 
nothing so much as the music hall ' professor,' whose lips 
put forth not wisdom — but yards and yards of pink paper. ' ' 
Most of his observations on the " architecture " of the 
body are either obvious platitudes or just nebulous 
nonsense. His innumerable anatomical illustrations 
illustrate nothing in particular. 

Excursions into the domain of pathology are fortunately 
rare : when they occur they are startling. Speaking of the 
causes of death, he tells us that " in the great majority of 
cases the terminal myocarditis is the cause of the stopping 
of the heart, but in not a few cases it is the result and 
not the cause of death." Again, discussing hearts, normal 
and abnormal, he divides them into two series. " In oua 



326 Revieics and BihliograpJiical Notices. 

we find stout, well developed valves, with normal amounts 
of fiber, well filled . . . but degenerated muscle. 
In another, weak, flniisy valves, either thin and trans- 
lucent or thick and opaque, and weak in fiber, while the 
musculation is fair or even good. More commonly both 
groups, the fihrinous and muscular, suffer together under 
some chemical organic or mechanical strain." 

What lesson these remarks are trying to instil we do 
not pretend to understand, but physicians are usually 
imbecile, and " the average pathologist has about equally 
clear ideas about the brain" — and we must assume about 
the heart also — "and. the telephone business or cauli- 
flowers." 

On questions of anatomy. Dr. Wadsworth is no less 
illuminating. " The sooner we grasp the fact," he writes, 
" that all anatomy is based on the principle of the number 
three the better." And then he teaches us that the 
mediastinum is not ' ' the space left by the non-approxima- 
tion of the two pleurae, but is the great central ligament 
of the diaphragm, and through that of the liver." No 
doubt the word mediastinum is another of " the mons- 
trously absurd names invented by the densely ignorant 
fathers of anatomy." But why become abusive about it? 
They said they meant the space between the pleura?, and 
a space cannot be a ligament. In any case, they had not 
the advantage of Dr. Wadsworth's book, nor of his epoch- 
making discovery of the new rule of three. 

All through the book we find a claim to a deeper know- 
ledge and understanding than is to be found among con- 
temporary workers in any field. He delights in putting 
posers to the experts and making capital of their discom- 
fiture. Dr. Wadsworth knows the answers himself, but 
he is not going to tell. This secretive attitude is often 
exasperating — for we really would like to know why 
" nobody would dream of giving a large dose of atropine 
to a person with yellow hair, or to cap the teeth of another 
whose hair happened to be red." 

The most useful chapter deals with the operator's 
arniiuiHMitariiuii. 



The Charlotte Medical Journal. 327 

The CJiarlotte Medical Journal. Vol. 73. No. 2. 
February, 1916. 

This number of the " Charlotte Medical Journal " is 
rich in the number of practical, readable and suggestive 
papers it contains. Dr. Payne writes of the use of local 
anaesthesia and of the advantages it possesses over general, 
anaesthesia so fervently that he almost persuades us to 
forswear ether, chloroform, and nitrous oxide, until at the 
close he reminds us that "it is wise that we be familiar 
with the contraindications to the use of local anaesthesia." 
And later on we read that the operator " must possess a 
thorough and comprehensive technical knowledge of the 
materials used." 

We have tried for many years to attain to this know- 
ledge of morphine, hyoscine, and cocaine, but success has 
not crowned our efforts, and we are consequently precluded 
from the use of local anaesthetics. Justice, however, de- 
mands that Dr. Payne's paper be recognised as an ex- 
haustive and valuable contribution to the study of anae- 
sthetics. "Fee Splitting" is the title of Dr. Leonard's 
article condemning this pernicious practice — which is 
both degrading to the medical profession and unjust to 
the patient. Dr. Cowell gives a terrible picture of the 
evils resulting from the abuse of narcotics in the United 
States of America in his paper " Opiumism." Narcotics 
are provided for sale under many fancy names, cocaine 
is supplied freely to negroes as " Joy Power." Caffeine 
forms an important ingredient in " Coca Cola " and 
"Pepsi Cola," which hundreds of men, women and 
children are daily drinking. In some instances the 
children of a family are trained to the use of morphine 
from birth. And, in the face of these facts, the 
author pleads that narcotic proprietary compounds 
should be prohibited. "Pernicious Purgation for Ab- 
dominal Pain " is the title of Dr. La-Eoque's protest 
against the indiscriminate use of purgatives in all forms 



328 Reviews and Bibliographical Notices. 

of abdominal pains, and a plea for a recognition of opium 
and other anodynes in such painful spasms as are not due 
to the presence of indigestible matter in the bowel. He 
also condemns the combination of anodynes and aperients ; 
yet we have found such a mixture to safely, quickly, 
and not unpleasantly effect much good, and it was 
a favourite with generations of practitioners. " A Medley 
of Errors " is a very long article, extending over fourteen 
columns — a reminiscence of the errors of five-and-twenty 
years' practice in mental diseases. It is a deeply interest- 
ing and very readable account by an able and morally 
brave alienist of errors in diagnosis and treatment. He 
tells — " Some patients have been badly treated through 
over-attention, while too often weak concessions have 
allowed hurtful privileges. The ignoring of some detail 
of investigation through false modesty, or that very 
human temptation to cross the line which separates pro- 
fessional from personal relations, and to respond in kind 
to the j)roffers of what we love to term ' sympathetic 
understanding,' have all been snares into which the 
ascendancy of the heart over the head has made damag- 
ing errors possible." 



Traumatic Pneumonia and Traumatic Tuberculosis. By 
F. Paekes Weber, M.A., M.D., F.K.C.P. (Lond.)'. 
Printed with Additions from Articles in the Clinical 
Journal, London, July, 1916. London : Adlard & Son 
and West Newman. 1916. 8vo. Pp. 63. 

The Workman's Compensation Act has brought into pro- 
minence many problems in Medicine which previously had 
received but little attention. Among such problems is 
the estimation of the influence that injury or accident has 
in the production of what formerly was looked on as purely 
medical disease. All sorts of illnesses have in recent times 
been attributed to injury and accident. To the sufferer 
the post hoc is very obvious, though to the medical assessor 
the acceptance of Uie propter hoc is equally difficult. For 



Report on Venereal Diseases. 329 

a long time the occurrence of pneumonia following, and 
evidently caused by, injury to the chest has been well 
recognised, though the explanation of the phenomenon 
has not been altogether satisfactory. The experiments of 
Ivulbs, of Leipzig, recorded in 1910, have thrown much 
light on the matter, and pneumonia due to traumatism of 
the chest is now as well recognised as fracture of the ribs. 
That an active pulmonary tuberculosis can be started as. 
a result of injury is by no means so well recognised, yet 
there seem.s to be no doubt of the fact. A latent focus of 
tuberculosis in the lung may be fanned into activity by in- 
jury just as readily as it may in any other part of the body. 
Dr. Weber has collected a number of cases illustrating 
these conditions, and his reasoning from the data pre- 
sented by him is both sound and instructive. ^Ye trust 
that his pamphlet will come into the hands of many- 
medical men, for we believe that they will find much of 
interest in it about an obscure though important problem. 



Report on Venereal Diseases. Issued under the Authority 
of the Minister for Trade and Customs, Commonwealth 
of Australia. State of Victoria : Albert J. Mullett. 
1916. Folio. Pp. 18. 

A MOEE valuable public document than this Eeport of a 
Committee concerning causes of death and invalidity in 
the Commonwealth of Australia we have seldom if ever 
perused. 

The Committee was appointed in connection with the 
Department of Trade and Customs, and the present Report 
on Venereal Diseases, including syphilis, soft contagious 
sore, and gonorrhoea, is signed by Sir H. B. Allen, M.D, i 
Dr. J. H. L. Cumpston, M.D. ; Dr. A. Jeffreys Wood, 
M.D. ; and James Mathews, M.P., Chairman of the Com- 
mittee. 

Sir Harry Brookes Allen and his medical colleagues were 
specially well qualified to draw up this admirable Report- 



330 Reviews and BibUograpliical Notices. 

Sir HaiTy is Professor of Pathology and Dean of the 
Faculty of Medicine in the University of Melbourne. He 
has been President of the Australian Medical Congress and 
of the Royal Commission on the Sanitary State of that 
great City. 

John Howard Lidgett Cumpston is the Director of 
Quarantine for the Commonwealth of Australia, and A. 
Jeffreys Wood is Honorary Medical Officer to the Chil- 
dren's Hospital, Melbourne. 

Nearly two-thirds of this Report of 18 folio pages are 
devoted to a description of the three forms of venereal 
disease named above. 

At page 12, there is a statistical summary of the pre- 
valence of venereal diseases in the military forces of the 
Crown. The figures for recent years go to show a gratify- 
ing decrease in the syphilis rate between 1905 and 1912. 
The gonorrhoea rate does not show any marked improve- 
ment. The explanation, no doubt, is that this malady is 
regarded as a trifling affection. 

Lieutenant-Colonel Gibbard, R.A.M.C. , attributes the 
improvement in the Army to — (1) improved methods of 
treatment ; (2) lectures and individual talks on the subject ; 
(3) increased tem})erance ; (4) increased attractions in bar- 
racks; (5) in India, in some degree, the Cantonment Act, 
1897 ; (6) improved education. He lays chief stress on 
improved methods of treatment and on lectures. 

The question of alcohol in relation to venereal disease 
is well answered in four ])ithy sentences as follows : — " In 
a large proportion of cases, a man is led into danger by 
loss of self-restraint through alcohol. It is believed by 
many that resistance to infection is (hminished by alcohol. 
Actual disease is li( up afresh by alcohol. Many of the 
most awful cases of syphilis of the nervous centres are 
partly conditioned by alcoholic excess." (Page 13. "i 

A nMml)er of excellent recommendations bring this able 
Report to a conclusion, the Committee quoting at the 
very tiid Paragraphs 237 and 239 of the Final Report of 
the British Royal Commission on Venereal Diseases, dated 
J-'cbiiiaiv II, lOIC). 



BOSANQUET — To.riiis' in Treat ninit cjid Didtjnofiis. 831 

Sfruins, Vaccines and I'o.rins in Treatment and Diaijnosis. 
By Wm. Cecil Bosanquet, M.A., M.D. (Oxon.), 
F.R.C.P. (Lend.) ; and John W. H. Eyre, M.D., M.S. 
(Dunelm), F.R.S. (Edin.). Third Edition. Modern 
Methods of Treatment Series. London, New York, 
Toronto, and Melbourne: Cassell & Co., Ltd. 191G. 
8vo. Pp. viii + 456. 

It is six years since tlie last edition of this book appeared, 
imd so much has been done, and such advances have been 
made in research, diagnosis, and treatment during that 
period, that an exhaustive revision of its contents has been 
found necessary, and nearly a hundred pages of new matter 
have been added. 

From our point of view, if another hundred pages had 
been incorporated in the book, giving us a further account 
of the authors' own experiences and conclusions, the book 
would not have suffered. The work lacks individuality. 
This is perhaps inevitable when there is more than one 
author, and where a large amount of material has to be 
confined within the hard and fast size and shape of some 
])articular series. Its crowded pages are packed with in- 
formation, but in reading, one has the sense of being 
hurried on to the next item, lest some omission should 
occur rendering the treatment of the subject incomplete. 

Collations and compilations entail a vast amount of 
conscientious collar work, but make ui)hill reading. 
Numerous authorities are cited, giving widely different 
views, and leaving behind a feeling of confusion as to net 
results, and sometimes of depression with the whole sub- 
ject. There is, however, an exhaustive bibliography which, 
taken together witii the glossary-like character of the 
wcrk, makes the book a useful one for reference. 

Some seventy pages are devoted to that therapeutic 
will-o'-the-wisp, tuberculin. The pursuit of success by 
its means in cases of phthisis leads nine times out of ten 
only to a " slough of desjiond," if not to more innnediate 
■disaster. 



332 Reviews and Bibliographical Notices. 

That this should be true of phthisis is, perhaps, not sur- 
prising, but that it should be a " most valuable remedial 
agent in tubercular disease of bones and joints, peritoneum 
and urogenitary tract," and of little or no use in lupus and 
adenitis, is a mystery. 

And even in these so-called surgical types of the disease 
how puzzling is its beiiaviour, how uncertain its action. 
Which of us has not seen a hitherto intractable lesion turn 
the corner, apparently under the influence of tuberculin, 
and finally get well, while the disease is breaking out in 
some other spot in the immediate neighbourhood, perhaps 
in a worse form than ever? 

And what are we to say of the dosage ? One enthusiast 
reports 50, 60, 100 per cent, of cures using a particular 
preparation, interval, and dose, with a lurid warning of 
catastrophe following any deviation from that line ; while 
" Specialist " in the next street records a very similar 
series of cures, using doses 50 or 100 times as great of the 
self -same preparation. As our authors say in another con- 
nection, " Credat Judaeus Apelles." 

The difference in the action of old and new tuberculin 
is well brought out, and worth remembering. 

Altogether, the book, with its neat binding and clear 
print, is a useful addition to the library of the immuno- 
logist, and a study of its pages will act as a check on the 
man of one idea. 

Early Works on the Sciences of Medicine and Chiriirgery. 
London : Charles J. Sawyer, Ltd. 

Charles J. Sawyer, Ltd., 23 Kew Oxford Street, 
London, is one of the few English Booksellers who publish 
catalogues dealing particularly with old medical books, 
and we have great pleasure in directing the attention of 
collectors to their present catalogue, which is before us. 
We can speak from experience of the courtesy of this firm, 
and also of the interest of the wares that are offered for 
purchase. Collectors of old medical books will do well to 
get into communication with Sawyer, Ltd. 



L'Ospedale Maggiore. 333 

L'Ospedale Maggiore. Rivista Mansile lUustiata. Ano 
lY. Xo. -2. 

This number of L'Ospedale Maggiore opens with a 
good clinical history of a case of primary cancer of the 
lung, which was diagnosticated during the life of the 
patient, by Dr. Paolo Pozzato. The value of the case is en- 
hanced by a bibliography given with a fulness which facili- 
tates reference. He truly states that primary cancer of 
the lung is seldom found in males, and is not unusually 
diagnosticated by means of an autopsy. Lavrinorick in a 
total of 16,047 patients found 1,620 cases of pulmonary 
cancer, and of these only 61 cases were of the primarj^ 
type. It is more prevalent in man than in woman, and 
is a disease of advanced life. Withal, he found some 
cases in patients between twenty and thirty years of age ; 
and he refers to Aldowic's case of an infant of five months 
and a half old. Of La\Tinorick's 61 cases 41 were males 
and 19 females. Dr. Pozzato considers that wounds are 
occasionally followed by primary pulmonarj^ carcinoma, 
and in one case of an injury of the sternum he ascribes the 
subsequent disease to the trauma. Cancer of the lung is 
also found to follow the inhalation of arsenic vapour pro- 
duced in extracting cobalt, and he mentions that arsenic 
when freely administered for the treatment of lymphosar- 
coma caused a malignant tumour. Thus, in some cases of 
(.ancer in organs other than the lungs the true cause re- 
mains oft-times unknown. Of Lavrinorick's cases the 
seat of the cancer was in the anterior lobe in 22 cases, 
(ince in the middle lobe of the right lung, and 17 times in 
the inferior lobe. The cancerous masses are usually 
found segregated in the centre of the lobe of the lung, 
l)ut sometimes they are diffused throughout the lung or 
along its border ; indeed, in some cases they are found 
in the bronchial walls, where they form cavities. 

Eascuna, in a paper before the Academy of Padua (1906), 
drew attention to the difficulty sometimes encountered in 
differentiating between the mass of cell epithelium of the 



334 Beviews and Bibliograpliical Notices. 

pulmonary alveoli and the matrix of a carcinoma. The 
symptomologv of pulmonary carcinoma closely simulates 
many other pathological conditions. AYhen a considerable 
amount of the parenchyma of the viscus is invaded by 
the growth it becomes dense, reducing the respiratory area 
so as to cause dyspnoea, a sense of suffocation, and of op- 
pression. It finally comes to press on the heart, disturb- 
ing the circulation of the blood ; causing breathlessness 
and angina pectoris. The participation of the pleura in 
the morbid process is characterised by a sharp pain, which 
not infrequently is of intense severity. The objective 
symptoms of the disease are various and complex ; the 
most trustworthy is that of Walski : an inhibition of the 
expansion and retraction of the thoracic walls. To tliis 
may, in advanced cases, be added a varicosity of the sub- 
cutaneous thoracic veins, occasioned by the intra-thoracic 
pressure exerted by the grow^th of the malignant tumour. 
When the disease has advanced somewhat the sputum 
assumes a gelatinous consistence and is stained to the 
colour of raspberry juice ; this is almost pathognomonic. Of 
course, as the disease advances, and the thoracic glands 
and larger bronchi are infected, the interference with 
respiration and circulation becomes painfully manifest. 
In a case occurring in the writer's practice, the disease 
extended to the superior vena cava, and the patient, a 
woman forty-five years of age, bled to death in a few 
minutes. Dr. Bozzato's patient came under his care 
on the 5tli April, 1915, at the Ospedale Maggiore. 
She menstruated at fourteen, was married at nineteen; 
was ten times pregnant, her last pregnancy terminat- 
ing in a miscarriage ; her menopause occurred at forty- 
four. Throughout her life she had enjoyed good health. 
In the October of 1914 she complained of a pain in the 
left side of her chest ; she felt unwell and was slightly 
feverish. Ai)out the middle of November she again pre- 
sented herself complaining of a cough and blood-stained 
fiputum. At that time, and for the six weeks following, 
ehe was apyretic. She was re-admitted to hospital, her 



UOspcihilv Macjgiore. 335 

appetite was ^ood, but she complained of a pain at the 
angle of the left scapula. The cough increased and the 
sputum continued the colour of raspberry juice ; pleuro- 
dynia became more severe ; laboured breathing and a sub- 
febrile temperature. She became gravely dis))irited ; her 
nuiscles were flaccid; the subcutaneous fat disappeared, 
and the skin assumed a pallid earthly hue. The cervical 
find inguinal glands were enlarged. Fluid was drawn off 
from the left ])leural cavity, the microscopic examination 
of which failed to throw any light on the nature of the 
case, other than that tubercle bacilli were present. The 
diagnosis of primary carcinoma was made on negative 
evidence of pneumonia, the apyretic temperature of the 
patient, profuse night sweats, intense pleurodynia, and 
a gelatinous raspberry juice coloured sjiutum. An ,r-ray 
ekiagraph gave colour to the opinion of a thoracic tumour. 

The autopsy revealed pericarditis w^ith very firm ad- 
hesion to the left lung, the surface of which was covered 
with whitish nodules. The pericardium was also thickly 
covered with very white nodules, especially marked in the 
auriculo-ventricular groove. The myocardium was thin 
and soft, brownish in colour and flabby; the endocardium 
was almost semi-fluid. The left lung w^as morbidly ad- 
herent to the pleura, and was marked throughout with 
grayish masses. The lymphatic glands were tumid, and 
contained some soft grayish nodules. The right lung was 
similarly affected as the left, but not to the same extent. 
On the right side the suprarenal capsule was affected 
and the left suprarenal capsule contained a grayish car- 
cinomatous nodule. 

As primary carcinoma of the lung is an unusual disease 
and one difficult of diagnosis in its early stage we have given 
an unusual amount of space to Dr. Paolo Pozzato's valu- 
able paper. Dr. Noel Orlandi's note on "A Cyst of the 
Thyroglossal Duct " follows, and is a contribution of much 
interest both from the anatomico-pathological point of 
view and from the clinical. The case which is the sub- 
ject of the paper was that of a male child of two years old 



336 Reviews and Bibliographical Notices. 

who was operated on for raniila, and died a few days 
afterwards of broncho-pneumonia. At the autopsy the 
cyst, which was the size of a pea, was found, of a firm con- 
Bistence of a regular form, situated in the middle line, 
and lying in the length of the organ. It contained mucus 
and inspissated epithelium of a grayish colour. 

Professor Gartano Parlaveccio contributes a twenty- 
page paper on modern therapy, which is too long to tran- 
scribe, and is of a character which does not admit of a 
summary. A brief and readable report is given of the new 
Polyclinic Hospital of Padua which is being erected. This 
is followed by some papers on medical politics of local 
interest, the whole making an interesting number. 



S. Weir Mitchell, M.D., LL.D., F.R.S., 1829-1914. 
Memorial Addresses and Eesolutions. Philadelphia. 
1914. Pp. 155. 

Although this handsome volume bears the date " 1914 " 
on the title page, it did not pass into our hands until the 
autumn of the present year. This must be our excuse 
for the lateness of the appearance of this notice. 

The work is really an "Edition de Luxe" of a fine 
tribute to the memory of a great American citizen, a 
physician of world-wide fame, a writer in poetry and 
prose of no mean parts, and a charming personality. 

The contents of the volume are a report of a special 
meeting of the College of Physicians of Philadelphia upon 
the death of Dr. S. Weir Mitchell, held on January 6, 1914 ; 
a " Minute " passed by the Board of Trustees of the Uni- 
versity of Pennsylvania, a " Minute of Appreciation and 
Esteem " adopted by the Council of the School of Medicine 
of the University of Pennsylvania, a " Minute " passed by 
the Directors of the Library Company of Philadelphia, a 
"Minute" passed by the Board of Trustees of the 
Jefferson Medical College of Philadelphia, a "Resolution" 
adopted on February 4, 1914, by tlie College of Physicians 
of J'hiladelphia inviting other Piibhc Bodies to join with 



S. Weir Mitchell, M.D. 337 

the College in a memorial meeting ; and a full report of 
the proceedings at a Joint Meeting of the College of 
Physicians of Philadelphia, the American Philosophical 
Society, the, University of Pennsylvania, the Library Com- 
mittee of Philadelphia, the Jefferson Medical College, and 
the Academy of Natural Sciences, held in the Hall of 
the College of Physicians on the evening of Tuesday, 
March 31, 1914, 

Both at the special meeting of the College of Physicians 
and at the joint meeting of the above-named learned 
bodies, eloquent tributes were paid to the illustrious 
physician and man of letters who passed away on January 
4, 1914, almost on the eve of his eighty-fifth birthday — 
Pebruary 15. The addresses at both meetings were worthy 
of the occasion. Their language was drawn from the 
springs of English pure and undefiled. At the joint meet- 
ing of scientific institutions on March 31, Dr. James 
Cornelius Wilson, President of the College of Physicians 
of Philadelphia, presided, and addresses were delivered by 
Mr. Talcott Williams, of Columbia University; Dr. Wil- 
liam H. Welch, of Johns Hopkins University; and Mr. 
Owen Wister, of Philadelphia. Dr. Welch spoke of Dr. 
;S. Weir Mitchell as the Physician and Man of Science ; 
Mr. Owen Wister, of him as a Man of Letters. 

From the splendid appreciation of Dr. Weir Mitchell 
fcy the last-named orator, we are tempted to quote a passage 
which seems peculiarly appropriate at the present time, 
when the British Empire and the Allied nations of the 
Entente are mourning their heroic dead in the great 
war : — 

" But beneath the generous scars in Dr. Mitchell's face 
lay something else, very special, plainly to be discerned 
not in him alone, but in great numbers of his generation. 
This is the deepest mark of all, this that he and a multitude 
of his fellow-countrymen bore ; and as it was set upon 
the man, so is it set upon his books; not one is without 
it ; it is mingled with the very essence of his writing. 

" Can not some of you remember old ]:)hotogra])h albums 

2 B 



338 Reviews and Bibliographical Notices. 

of the 'sixties' ? Have you not sometimes, in some drawing- 
room, while you waited for your hostess to come down- 
stairs, turned the leaves of such an album? I can think 
of one now. Among its ancient faces, quaint in old 
fashions, are pictures of soldiers— young soldiers gener- 
ally ; mere boys quite often. They wear sabres and visored 
caps and boots to their knees. Out of these small, dim, 
carte-de-visite album windows these boys look at us across 
fifty years. As we gaze at them the strange fancy comes 
that, could they open their lips and speak, they would all 
say the same thing ; in their silence they seem to share 
something of solemn import. Thousands of houses have 
such albums. If the photographs were coloured, some of 
the uniforms would be blue, some gray, but in whatever 
colour they are clad, the same look is in all these boys. 
Charleston and Richmond differ not from Boston and 
Philadelphia. No matter which the uniform of the young 
soldiers, the same beautiful serious light shines upon their 
faces — the glow of dedication. Not on soldiers only did 
the Civil War thus set its seal, but upon all patriotic men 
and women also. And so that generation saw a vision 
that we see not, and wrote with a pen that never can be 
ours. Fined in a white-hot furnace, it emerged with eyes 
which had seen our country battling for her soul with 
naked sword. Through four long years that generation 
had witnessed this : how should it not thereafter look at 
the world and time, and eternity, with a special gaze of 
its own? To Dr. Mitchell came hundreds of the maimed 
and wounded from that conflict. Wounds, blood, agony,, 
and noble courage were for him a daily sight. In hospitals 
he helped to save the men, or saw them die. Never could 
he be the same again. Whatever his thoughts thenceforth, 
deep down was that memory perpetual. During the last 
five days of his illness his wandering mind returned to 
those scenes ; his wandering talk was of mutilation and 
bullets ; he conversed and argued with that past. There- 
fore, it IS that when we read his tales and poems, no matter 
wliat be their subject, all come from a spirit over which 



McKemdkick— l^ac/;: Injuries. 339 

had passed the great vision ; every drop of ink is tinctured 
with tlie blood of the Civil War." (Pages 135-137.) 

Dr. William H. Welch, of Johns Hopkins University, 
President of the National Academy of Sciences, paid a 
glowing" tribute to the memory of his friend and co-worker 
in the common field of biological research as applied to 
Practical Medicine. With the eloquent peroration of Dr. 
Welch's fine address w'e bring this notice to a close : — 

However the verdict of history may modify contem- 
porary judgments of the achievements of men, it cannot 
change the place which Dr. Mitchell holds in our affection 
and esteem. He was a great physician : our leader, en- 
deared, admired; our friend and counselor, generous, wise, 
inspiring; a man of singular graces and accomplishments, 
active in advancing knowledge and in good works, a poet 
and a man of letters, a sweetener of life to both sick and 
well. Happy such a life and happy the memories there of 
which we shall ever cherish ! As he said of Harvey, we 
may say of him — Weir Mitchell represented all that is 
best in the physician and the gentleman." (Page 127.) 

J. W. M. 

Back Injuries and their Significance under the Work- 
men's Compensation and other Acts. By Archibald 
McKendrick, F.E.C.S.E, &c., Surgeon-in-charge of 
X-ray Department, Eoyal Infirmary, Edinburgh. 
Edinburgh : E. & S. Livingstone. 1915. 8vo. Pp. viii 
+ 173. 

This is a very thorough, simple, and instructive book on 
a subject that is quite overlooked in the average text-book. 

Besides being of great use to the civil practitioner it 
will prove of great value to all Army Surgeons who are 
dealing with the frequent cases of obscure spinal injuries 
which occur so frequently in the present war. 

With particular interest will be read the author's ac- 
count of the abnormalities of the fifth lumbar vertebra, 
as shown by a;-ray photographs. 

H. S. 



340 Eevieics and Bibliographical Notices. 

A Practice of Gyncrcologij. By Heney Jellett, M.D. 
(Univ. Dubl.), F. E.G. P.I. , Master Eotiinda Hospital, 
&c. Being" the fourth edition, revised and enlarged, of 
"A Short Practice of Gyn£ecology." With 374 illus- 
trations (many in colours) and 11 coloured plates. 
London: J. & A. Churchill. 1916. Pp. xii. + 618. 

A LAKGE number of practitioners and students had eagerly 
awaited the publication of a new edition of Dr. Jellett 's 
gynaecology, for the third edition had been out of print 
for some time. The present volume is greatly increased 
in size, and is improved in many ways. Approximately, 
one-half of the book is devoted to the discussion of sym- 
ptoms, signs, and treatment, while the remaining half 
consists of descriptions of the various operations. 

There are several new paragraphs dealing with 
leucorrhoea, and the chapter on the positions of the uterus 
is amplified. There is an excellent monograph on vaccine 
therapy in gynecology, and radiotherapy is meticulously 
described. 

The portion of the work dealing with operative gynae- 
cology appeals greatly to us. The author apologises in his 
preface for the non-acknowledgment of borrowed illus- 
trations, but some of the best are the new original 
illustrations. There is a most descriptive diagrammatic 
picture of the different methods of performing hyster- 
ectomy. A vast improvement is the fact that Dr. Jellett 
describes and illustrates such operations as perinfporrhaphy, 
partial amputation of the cervix and subtotal hysterectomy 
as he himself performs them. In past editions we were 
accustomed to read about Warder's hysterectomy, La wson 
Tait's ])erincX'orrhaphy, &c. The extremely comprehensive 
studies illustrative of the author's personal experience is 
particularly satisfactory, and will be intelligible even to 
the man who has never held a knife in his hand. The 
operation of interposition of the uterus is described in few 
text-books, and we are glad to find here a full description 
with illustrations. We might call attention to a misprint 
in figure 343, where the word " inversion " is used instead 
of " inter[)osition." Prolapse of the uterus is considered 
fully, and the author, we are glad to find, insists on a 



University Calendars. 341 

thorough repair of the anterior and posterior vaginal walls, 
circular amputation of the cervix, shortening of the utero- 
sacral ligaments, and, in some cases, interposition of the 
uterus for the cure of this grievous trouble. There 
are far too many lazy operators who perform only perina'- 
orrhaphy and ventral suspension in an effort to cure a 
prolapse, with the result that the woman leaves the hos- 
pital in as bad a condition as she entered. In the removal 
of ovarian tumours it is advised, where possible, to make 
an incision large enough to deliver them en masse. The 
treatments of prolapse and of ovarian tumours condemn 
the general surgeon who potters in gynaecology. Gyna'- 
cology is so important, and the future of the race depends 
so much on a competent practice of the art, that we would 
gladly welcome a law forbidding anyone but specialists 
from operating on the organs peculiar to women. 

Everything new in gynaecology will be found by the 
reader of this extremely successful book, which is ai)out 
the best of its kind in the English language. 

B. S. 

UNIVERSITY CALENDARS. 

1. TJie Dublin University Calendar for the Year 1916-1917, 
to ichieli are added the Ordinary Papers set in the Year 
1915-1916. Volume I. Dublin : Hodges, Figgis & Co., 
Ltd. 1916. 8vo. Pp. viii + 64 + 350 -I- cxxii. 

2. Tlie National University of Ireland. Calendar for the 
Year 1916. Dublin : Alex. Thom & Co. 1916. 8vo 
Pp. viii + 543. 

1. The first volume of the Dublin University Calendar for 
the coming academic year was published as usual in good 
time towards the close of September. 

Special reference is made at page viii. to the principal 
changes in the courses of study made in the year 1915-1916. 

Those changes which concern medical students will be 
found at pages 52 and 60 taken in connection with the 
special regulations for medical and dental students who are 
proceeding to the Arts Degree. These special regulations 



342 Reviews and Bibliographical Notices. 

are set out fully at pages 266 to 269 inclusive. Lectures 
and an examination in Organic Chemistry are now required 
in the second year's course. The examination in this sub- 
ject falls under the heading ' ' Intermediate Medical Ex- 
amination, Part I." (See page 245.) Only a paper will 
be set in Organic Chemistry, no oral or practical examina- 
tion being required in this subject. 

Regulations respecting examinations in the School of 
Physic and the School of Dental Science are given in a 
concise form at page 283. On that page mention is still 
made of " Liceat Fees," but a note at foot of page 247 
carries the welcome intelligence that these liceat fees are 
not charged to students who have matriculated in the 
School of Physic subsequent to May 22nd, 1915. 

The conditions and terms of appointment to the " Mary 
Louisa Prentice Montgomery Lectureship in Ophthal- 
mology," founded in 1915 by the late Robert John Mont- 
gomery, M.A., M.B. (Dubi.), F.R.C.S.I., are duly set 
forth at page 278. Our readers will remember that the 
first lecturer is Dr. Euphan Montgomery Maxwell, whose 
lecture on " Uveitis " was published in the number of this 
Journal for August and September of this year (see pages 
94 and 158). Dr. Maxwell's appointment bears the date 
July 6, 1916. 

The Editor, Mr. M. W. J. Fry, M.A., F.T.C.D., is 
to be congratulated on his handiwork, as displayed in the 
Calendar. 

2. The publication of the " National University Calendar" 
for the present year was especially belated. The volume 
did not appear until late in August. A contributory 
cause of this was the destruction by fire of the great 
printing offices of Messrs. Alex. Thom & Co. in the Sinn 
Fein rising of Easter Week, 1916. 

The Calendar contains the usual information relative 
to the University and to its constituent Colleges in 
Dublin, Cork and Galway. A recognised College of the 
University also is St. Patrick's College, Maynooth, the 
teaching staff of which Institution is nanied at page 47. 



Waterston' — Fleas as a Menace, tu Man. 343 

The progress of the University may be gauged by the 
number of candidates who passed and the number of 
students who failed at the Matriculation Examinations 
in 1915. Of 93'2 candidates, 618 passed and 314 failed. 
Besides these candidates, 176 students matriculated on 
the results of Examinations held by outside Bodies, 
accepted by the Senate as equivalent to the Matricula- 
tion Examination, and 16 students matriculated b}^ pass- 
ing in certain subjects at the Summer Matriculation 
Examination and in the remaining necessary subjects at 
the Senior Grade Examination, 1915, of the Interme- 
diate Education Board. 

The accession of numerical strength to the University 
in 1915, therefore, works out at 810. 

Fleas as a Menace to Man and Domestic Animals : 
Their Life History, Habits and Control. By James 
Waterston, B.D., B.Sc. ; Entomological Assistant, 
Imperial Bureau of Entomology, London. British 
Museum (Natural History) Economic Series, No. 3. 
London : William Clowes & Sons, Ltd. 1916. 8vo. 
Pp. 21. One Plate and 6 Text-figures. 

The important part played by fleas in the transmission of 
certain acute infections — notably bubonic plague, and less 
certainly typhus fever — lends a lively medical interest to 
this eminently scientific contribution to entomology. 

Mr. Waterston tells the story of the flea in a singularly 
clear and interesting manner. It will, perhaps, surprise 
our readers to learn that about five hundred kinds of fleas 
have been described, of which about ©ne-tenth (46) are 
found in Britain, while at least twenty-six species have 
l)een recorded from the Brown or Norway Eat {Epimys 
norvegicus) ; the Black Rat (Epimys rattus) ; and the 
House Rat {Mus musculus) in various parts of the world. 
Of these twenty-six species, eight are known to carry 
plague, under favourable conditions, while in addition two 
squirrel fleas (North America) and another from Man- 
churian " Tarbagans " (Arctomys hohac) play the same 
role. In all, then, eleven fleas have, up to the present, 
proved capable of transmitting plague. Five of them are 
common British species, while a sixth, the Plague Flea 



344 Reviews and Bibliographi'cal Notices. 

par excellence {Xenopsylla cJieopis), is occasionally intro- 
duced to our shores. 

Mr. Waterston does not leave his reader in ignorance 
as to " Flea control." The measures to be taken to get 
rid of fleas are set forth in simple, telling language at 
pages 18 to 20. His erudite yet easily understood paper is 
the third of a series of pamphlets and leaflets of economic 
interest which is in course of publication by the Natural 
History Museum, Cromwell Eoad, London, S.W., at 
which any of the series can be obtained. The cost of Mr. 
Waterston's pamphlet is one penny, postage extra — good 
value for the money. 

INDIAN MEDICAL SERVICE. 

In \'lew of the present great need for experienced officers in 
the Indian Medical Service the Secretary of State for India 
has approved a proposal of the Government of India to retain 
in their appointments, when it is considered desirable in the 
public interest, Colonels of the Indian Medical Service after 
they have completed the ordinary period of tenure or would 
in ordinary circumstances be placed on the retired list. In 
order, however, to obviate the block in promotion which would 
thereby occur, such officers are regarded as supernumerary 
in their rank, and promotions are being made ia sviccession. 
For similar reasons the following special arrangements have 
also been made in the case of Lieutenant -Colonels who, under 
the terms of the Royal Warrant governing promotion in the 
Indian Medical Service, may be specially selected for increased 
pay for ability and merit. The number of officers eligible for 
this mcrease of pay is at present fixed at forty-one. Among 
such of these as retire in any one year four extra pensions of 
£100 per annum are distributable subject to certain conditions. 
Retirements being suspended during the War. the Secretary 
of State for India has decided as a measure of reUef — (I) that 
provided there are a sufficient number of applicants who 
satisfy the required conditions, these four extra pensions, 
which would otherwise lapse, shall be allotted in each year, 
but that payment of the extra pensions shall be held over until 
the allottees have actually retired ; and (2) that such recipients 
shall be regarded as supernumerary on the list of forty-one 
selected Lieutenant-Coloriols, and that promotions to the list 
shall be made in their place. 



PART III. 
MEDICAL MISCELLANY. 



Ueports, Transactions, and Scientific Intelligence. 



me:\ioeial to the late SIE HEXRY SWANZY, 

M.D. 

An interesting ceremony took place at the Eoyal Victoria 
Eye and Ear Hospital, Adelaide Eoad, Dublin, on the after- 
noon of Tuesday-, October 17 (St. Luke's Eve), when His 
Grace the J\Iost Eeverend John Henry Bernard, D.D., 
D.C.L., Archbishop of Dublin, unveiled a memorial to the 
late Sir Henry E. Swanzy, the famous oculist. Viscount 
Monck presided, and there was a large attendance of the 
Medical Profession, the friends and supporters of the Insti- 
tution, and the personal friends of Sir Henry Swanzy. 

The Chairman said they were assembled to do honour to 
a very distinguished man, whose name was known through 
the Continent of Europe nearly as well as it was in Dublin. 
They all knew what Sir Henry Swanzy had done for that 
hospital. He had worked for years for the amalgamation of 
the two hospitals which had previously existed, with the 
result that they now possessed the splendid Institution in 
which they were assembled. He was glad that the new 
wing was called the " Swanzj' Wing " (applause). 

Mr. J. B. Story, Vice-President of the Eoyal College of 
Surgeons in Ireland, stated that the Committee which had 
been engaged in the erection of the memorial to Sir Henrj' 
Swanzy was appointed on July 3rd, 1913, at a public meeting 
held in the Eoyal College of Surgeons. As a result of this 
meeting a sum of £1,422 was subscribed, the subscriptions 
coming from all kinds and conditions of sympathisers — 
DQembers of the medical profession in Ireland and Great 
Britain, and past pupils of the hospital; distinguished oph- 
thalmologists and aurists on the Continent of Europe, in Asia,. 



346 Memorial to the late Sir Henry Swanzy, M.D. 

America, Australia, New Zealand; and Sir Henry's own 
countrymen in Ireland and Great Britain as well as in Dublin. 
The contributors appeared to be persons who knew Sir Henry, 
not alone in his public capacity, but personally. Of the 
sum subscribed, £1,000 had been devoted to paying off part 
of the debt incuiTed in building the west wing of the hospital, 
which was the last work of construction undertaken in the 
life of Sir Henry Swanzy. Some of the balance had been 
used in necessary structural alterations required to form an 
alcove to contain the memorial, designed and very kindly 
carried out by Mr. Batchelor. It was estimated that after 
all expenses were paid there would be a further sum of over 
£140 to hand over to the treasurers of the hospital. 

The President of the Eoyal College of Surgeons (Mr. 
William Taylor) said it was indeed a great pleasure and 
privilege to him to be asked to speak on that occasion 
of his friend, the late Sir Henry Swanzy. The recital 
of a few points of Sir Henry's career would serve to 
'show what a great man he was. He graduated in Dublin 
University in 1865, took the licence of the College of Surgeons 
in 1866, and its Fellowship in 1875. He then studied in 
Vienna and Berlin for two years, and was assistant to the 
greatest oculist of the day. Subsequently he served in the 
German Army as a surgeon during the Franco-Prussian War. 
He returned to Dublin after four years' absence, and settled 
<lown to practise as an ophthalmic and aural surgeon, in 
which practice he acquired a great reputation. He acted f»r 
several years as surgeon to the National Eye and Ear Infir- 
mary, and was largely, if not mainly, instrumental in found- 
ing the splendid institution in which they were now 
assembled. His reputation rapidly grew, and in 1888 he had 
conferred on him the highest honour which an oculist could 
receive, namely, that of being selected by the Ophthalmic 
Society of the United Kingdom to deliver the Bowman Lec- 
ture. His reputation was by that lecture established in 
America, and as a result, he was asked to write an article, 
which was really a monograph on eye diseases and eye 
symptoms in their relation to the organic diseases of the 
brain and spinal cord. That article was generally held to be 
the most authoritative one on the subject. In 1905 his own 
University of Dublin conferred on him the degree of M.D. 
■honoris causa. He was elected President of the Eoyal 



Memorial to the late Sir Henry Swanzy, M.D. 347 

College of Surgeons in 1900, and had the honour of knight- 
hood conferred on him in 1908. The final honour conferred 
on him was in 1913, the year of his death, when he was 
elected President of the Ophthalmological Section of the Inter- 
national Congress of iMedicine, which was held in London. 

Swanzy was a leading authority, recognised by all the 
world in ophthalmological science. His professional cai'eer, 
as his private life, stood without blemish. He was 
the soul of honour. His ideals were high and his ethics were 
unimpeachable. He was a loyal friend to those whom he 
• trusted, and he was equally strong in his dislikes. His 
memory would long be cherished by those who enjoyed the 
honour of his friendship. A man who sei-ved his day and 
race — as Sir Henry Swanzy did — required no eulogy from 
the President of the Eoyal College of Surgeons. 

The Archbishop of DubHn said he was grateful for the 
privilege of being associated with the proceedings of that 
day. When his old friend, Mr. Story, asked him to attend, 
he accepted the invitation with peculiar satisfaction — not 
only because he knew something of Sir Henry Swanzy 's 
scientific eminence, but because of late years he had begun 
to feel he could look upon him as a friend. He was intro- 
duced to Sir Henry some 15 or 16. years ago, and became 
associated with him to a small extent in the work of the 
Research Defence Society, in which 'he was interested as a 
jiiember of the general public. They had heard from the 
President of the College of Surgeons what the nature of Sir 
Henry Swanzy 's life work was, -how greatly it was valued, 
•and how widely read were his works. Even those who were 
not scientific men knew, or realised to some extent, how 
rich was Sir Henry's culture and how varied his experience, 
, and v\ith what respect his name was always received by 
members of his great profession. That hospital was one of 
the successful establishments for which Sir Henry Swanzy 
was responsible, and it was because of his indomitable per- 
severance that all the difficulties were overcome. It was 
specially fitting that his name should be preserved in an 
institution where the poor, for whose sorrows he always had 
a great pity, were attended to with care and skill. 

His Grace then unveiled the memorial, a bronze tablet 
containing a striking likeness of the late Sir Henry Swanzy. 



348 War Time. Economy : A Medical Grievance. 



WAR TIME ECONOAIY: A MEDICAL GEIEVANCE. 

The following letter was addressed to the Editors of the 
Dublin daily newspapers: — 

Sir, — On June 17th of the pi'esent year the Local Govern- 
ment Board of Ireland issued the following circular letter to 
all County Boroughs, Urban and Eural Districts where the- 
Infectious Disease (Notification) Act, 1889, or Part I, of the- 
Tuberculosis Prevention (Ireland) x\ct, 1908, had been 
adopted; but, so far as I know, to no body representative of, 
or connected with, the medical profession in this country : — 

1' Local Government Board, 

" Dublin, llth June, 1916. 

" Sir,— Adverting to their circular letter of the 5th inst., on 
the subject of the Local Government (Emergency Provisions)' 
Act, 1916, I am directed by the Local Government Board 
for Ireland to draw the special attention of the Sanitary 
Authority to Section 5 of the Act, fixing at one shilling the 
fee payable to a medical practitioner for a certificate or noti- 
fication duly sent by him in accordance with the provisions 
of Section 4 (2) of the Infectious Disease (Notification) Act, 
1889, and Section 1 (5) of the Tuberculosis Prevention (Ire- 
land) Act, 1908, in respect of a case of disease to which these 
sections apply occurring in his private practice. 

"Notwithstanding the provisions of Section 15 of the 
Infectious Disease (Notification) Act, 1889, it is also 
provided that every case of such disease occurring in 
building, tent, van, shed, or similar structure in the 
occupation of any of His Majesty's Forces or of any 
I)erson employed by or under the Admiralty, the Army 
Council, or the Minister of Munitions, should be duly 
notified to the Medical Officer of Health, and payment 
made in respect thereof by the Local Authority to the medical 
attendant (unless he is a medical officer who holds a Com- 
mission in any of His Majesty's Forces) of a fee of one 
shilling for each case so notified, whether the case occurs in 
his j)rivate practice or otherwise. 

" It will be observed that Section 5 of the Local Govern- 
ment (Emergency Provisions) Act is to have effect only during 



War Time Economy : A Medical Grievance. 349 

the continuance of the war, and afterwards for such period or 
periods, if any, not exceeding one year, as the Local Govern- 
ment Board may fix (Section 24). 

" I am, Sir, 

" Your obedient Servant, 

" A. K. Barlas, Secretary." 

To understand what has happened, it will be necessary to 
quote Sub-section (2) of Section 4 of the " Infectious Disease 
(Notification) Act, 1889." It runs as follows: — 

" 4. — (2) The Local Authority shall gratuitously supply 
forms of certificate to any medical practitioner residing 
or practising in their district, who applies for the same, 
and shall pay to every medical practitioner for each cer- 
tificate duly sent by him in accordance with this Act, a 
fee of two shillings and sixpence, if the case occurs in his 
private practice ; and of one shilling if the case occurs in 
his i^ractice as medical officer of any public body or in- 
stitution." 

It is necessary also to observe that Section 3 of the same 
Act requires a medical practitioner attending on or called in 
to visit a patient suffering from an infectious disease to which 
the Act applies to notify the fact under a penalty. Sub- 
section (2) of this section iims thus : — 

" Every person required by this section to give a notice 
or certificate who fails to give the same shall be liable 
on summary conviction in manner provided by the Sum- 
mary Jurisdiction Acts to a fine not exceeding forty 
shillings." 

Nor is this all. A medical practitioner who makes a mis- 
take in his diagnosis, or innocently certifies in error, may be 
• exposed to the danger of having an action for damages brought 
against him in the civil courts by the patient or the patient's 
jrelatives. 

Enough has been stated to show that the duty of notifica- 
tion is compulsory, one of grave responsibility, and one which 
may be attended by unpleasant and serious consequences to 
members of the medical profession. Surely, for a medical 



350 War Time Economy : A Medical Grievance. 

certificate issued amid such surroundings a fee of two shil- 
lings and sixpence is poor remuneration at the best. x\nd 
yet, under the Local Government (Emergency Provisions) 
Act, 1916, this totally inadequate sum is whittled down to. 
one shilling, which practically amounts to a war tax on noti- 
fication fees of 60 per cent. 

Notification has now been in operation since 1889 — a period 
of 27 years ; and, no matter what the public may think of its 
value, sanitarians have no doubt that it is a powerful agent 
for good in the attempt to control the prevalence of acute 
infectious diseases. 

"Will the effectiveness of notification as a measure of Pre- 
ventive Medicine be increased by taxing the Medical Pro- 
fession, always ready — perhaps too ready — to place their- 
services at the disposal, and for the benefit, of the community 
— to the extent of 60 per cent, in this matter of medical cer- 
tificates under the Notification Acts? 

Is it not a fact that members of the House of Commons, 
through which the Emergency Provisions Act, 1916, passed, 
a few months ago, are still drawing their salary of £400 a 
year without any deduction whatever? 

I am. Sir, 

Yours faithfully, 
John W. Moore, M.D., D.P.H., F.E. C.P.I. 

40 FiTzwiLLiAM Square, 

DuBLix, Octoher IQth, 1916. 



ROYAL COLLEGE OF PHYSICIANS OF lEELAND. 

The 224th Annual Meeting of the President and Fellows of 
the Royal College of Physicians of Ireland was held in the 
College Hall, Kildare Street, on St. Luke's Day, Wednesday, 
October 18th, 1916. 

The following elections were made: — President — Dr. 
Joseph O'CaiToll. Vice-President — Dr. Bewley. Censors — • 
Dr. Henry Bewley, Dr. Martin Dempsey, Dr. W. A. Winter, 
Dr. B. Solomons. Examiners for the License to Practise 
Midwifery — Dr. Hastings Tweedy and Dr. Spencer Sheill. 



Royal College of Pliysicians of Ireland. 351 

Additional Examiners to take the place of an absent Censor 
or Examiner — Medicine, Dr. W. Boxwell; jMedical Juris- 
prudence and Hygiene, Dr. Falkiner; jSIidwifery, D*. 
Spencer Sheill. Supplemental Examiners under the Con- 
joint Examination Scheme — Biology, Dr. George. E. Nesbitt; 
Chemistry, Dr. Ninian Falkiner; Physics, Dr. W. G. Harvey; 
Physiology, Dr. H. C. Earl; Anatomy, Dr. E. J. Eowlette ; 
Pathology, Major F. C. Purser; Pharmacy, Materia Medica, 
and Therapeutics, Dr. George Peacocke ; Medicine, Professor 
T. G. Moorhead. Examiners for the Conjoint Diploma in. 
Public Health — Hygiene, Dr. S. T. Gordon; Bacteriology, 
Dr. H. C. Earl; Sanitary Law and Vital Statistics, Dr. 
Ninian Falkiner; IMeteorology, Dr. A. J. Matson. Examiners 
for the INIembership — Clinical Medicine, Dr. Bewley and Dr. 
Dempsey; Practice of Medicine, Dr. Winter and Dr. Nesbitt; 
Pathology, Dr. Earl and Dr. O'Sullivan; Obstetrics and 
Gynaecology , Sir Andrew Home and Dr. E. H. Tweedy. 
Eepresentative of the College on the General Medical Council 
— Sir John W. Moore. Eepresentatives of the College on 
the Committee of INIanagement — Dr. Walter G. Smith, Sir 
John W. INIoore, and Dr. T. Percy C. Kirkpatrick. Treasurer 
— Dr. Henry Bewley. Eegistrar — Dr. T. Percy C. Kirk- 
patrick. Librarian — Mr. Eobert Phelps. Agent to the 
Trust Estate — Messrs. Towns'hend. Law Agents — Messrs. . 
Stephen Gordon, Son, and Wilson. 

INDIAN MEDICAL SERVICE. 

The Secretary of State for India has decided that any officer 
appointed by nomination to the Indian Medical Service 
during the present suspension of appointments by competitive 
examination shall be allowed to count — 

1. As Service for Pension. — Any service rendered by him. 
during the present war as a medical combatant officer or in 
a position usually filled by an officer. 

2. As Service for Promotion. — Any service rendered after 
16th July, 1915, which counts for pension under 1. 

The reason for confining the service, specially counting 
for promotion to service rendered after 16th July, 1915, is 
that this condition is necessary in order to prevent officers 
appointed by nomination during the suspension of appoint- 
ments by competitive exammation from obtaining seniority 
over those previously appointed by competitive examination. 



SANITAEY AND METEOROLOGICAL NOTES. 

Vital Statistics. 
For four tceeks ending Saturday, October 7, 1916. 
IRELAND. 
The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institu- 
tions from without the respective districts — registered in 
the week ended Saturday, October 7, 1916, in the Dublin 
Registration Area and the eighteen pri^ciisal provincial Urban 
Districts of Ireland, was 15.7 per 1,000 of the aggregate 
population, which for the jDurposes of these returns is esti- 
mated at 1,122,268. The deaths from all causes registered 
in the week ended Saturday, October 7, and during the 
period of four weeks ended on that date, respectively, were 
equal to the following annual rates per 1,000 of the popu- 
lation. 

Nineteen Town Districts, 15.7 and 15.9; Dublin Registra- 
tion Area, 18.7 and 17.5; Dublin City, 20.1 and 18.3; Belfast, 
14.0 and 13.7; Cork, 14.3 and 16.0; Londonderry, 15.6 and 
16.6; Limerick, 13.5 and 18.9; and Waterford, 28^5 and 20.4. 

The deaths from certain epidemic diseases — namely, enteric 
fever, typhus, small-pox, measles, scarlet fever, whooping- 
cough, diphtheria, dysentery, and diarrhceal diseases — regis- 
tered in the 19 town districts during the week ended Satur- 
day, October 7, were equal to an annual rate of 2.0 per 
1,000. Among the 105 deaths from all causes in Belfast 
were 1 from enteric fever, 1 from measles, and 4 from 
diarrhoeal diseases. The deaths of 2 children, both under 
2 years of age, from " diarrhoea and enteritis," are included 
in 21 deaths from all causes registered in Cork. Of the 12 
deaths registered in Londonderry 3 were of children under 
2 years of age from diarrhoea and enteritis. Two deaths 
from measles are included among 15 deaths recorded in 
Waterford. Of 3 deatbs recorded in Lisburn 2 were of 
children under 2 years of age from diarrhoea and enteritis. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin 
as extended by the Dublin Corj)oration Act, 1900, together 
witli the Urban Districts of Ratbmines, Pembroke, Black- 
rock and Kingstown. The population of the area is 397,000. 

In the Dublin Registration Area the births registered during 



Sanitary and M eteorological Notes. 353 

the week ended October 7 ainouuted to 204 — 109 boys and 
95 girls, and the deaths to 146 — 77 males and G9 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 4) 
of persons admitted into public institutions from localities 
outside the Area, represent an annual rate of mortality of 
18.7 per 1,000 of the population. During the forty weeks 
ended with Saturday, October 7, the death-rate averaged 
19.9, and was 1.6 below the mean rate for the corresponding 
portions of the 10 years 1906-1915. The rate for all deaths 
registered during the forty weeks w^as 21.5, and in the cor- 
responding period of the preceding 10 years it had been 22.7. 

The 142 deaths appertaining to the Area included 3 from 
enteric fever, 3 from whooping cough, 3 from diphtheria, 1 
from influenza, and 15 from diarrhoeal diseases. In the 3 
preceding weeks deaths from enteric fever had numbered 
0, 2, and 4; deaths from whooping-cough, 0, 1, and 1; and 
deaths from diarrhceal diseases, 33, 24, and 17 respectively. 
No deaths from influenza had occurred during the three pre- 
ceding weeks. 

Tuberculosis caused 23 deaths, as against 19, 18, and 18, 
lespectively, in the three weeks preceding. Of the 23 deaths 
ascribed to tuberculosis, 16 were referred to pulmonary tuber- 
culosis, 1 to tuberculosis of the nieninges of the brain, and 
6 to other forms of tuberculosis. 

Twelve deaths were caused by cancer, 12 by pneumonia 
(4 by broncho-pneumonia and 8 by pneumonia, type not 
distinguished), 13 by organic diseases of the heart, and 11 by 
bronchitis. 

Among 10 deaths of infants under one year old, 4 were 
ascribed to convulsions, 3 to congenital debility, 2 to pre- 
maturity, and 1 to congenital malformation. 

Three deaths were due to violence ; there were two suicides, 
and 1 death was the result of a railway accident. 

Fifty-five of the deaths registered during the week apper- 
taining to the Area were of children under 5 years of age, 35 
being infants under one year, of whom 10 were under one 
month old. 

Of the 142 deaths recorded, 50 occurred in hospitals and 
other public institutions. 

STATE OF INFECTIOUS DISEASE. 

The following returns of the number of cases of Infectious 

2 c 



354 



Sanitary and Meteorological Notes. 



Diseases notified under the " Infectious Diseases Notifica- 
tion Act, 1889," and the " Tuberculosis Prevention (Ireland) 
Act, 1908," have been furnished by the respective sanitary 
authorities : — 

Table 1. — Showing the Number of Cases of Infectious Diseases notified in tin 
Dublin Registration Area — (viz., the City of Dublin and the Urban Districts o 
Eathmines and Rathgar, Pembroke, Blackrock and KingstoAm), and in the Citic 
of Belfast, Cork, Londonderry, Limerick, and Waterford, during the week end( < 
October 7, 1916, and each of the preceding three weeks. 
A dash ( — ) denotes that the disease in question is not notifiable in the District. 



Cities \'^n Week 

'iiMAN DlSTlllcrs emliiiK 



City of DiiblJii 



RaDiiiiine.s and 
Ratligav 
Ury)iin 
ninliict 

I'eiiiliroke 
Disliici 



BlackrocU 
Ur))aii 
District 



KillJ^Mlowii 
Url)aii 
Disl.iicrt 



City of lielfiiHl 



City of Cork 



(^ity of Lomlon- 
derr) 



City of Minciicli 



Cityof WiiliTfo.iI 



Sept. 16 
Sept. '23 
Sc-pt. 30 
I'ct. 7 

Sept. 16 
.Sei,t. 23 
Sept. 30 
Oct 7 

Sept. 16 
.Sept. 23 
Sept. 30 
Oct. 7 

Sept. 16 
Sept. 23 
Sept. 30 
Oct. 7 

Sept 16 

.Sept. 23 

Sept. 30 

Oct. 7 

Sept. 10 
Se|)t. 2a 
Sept. 30 
Oct. 7 

Sept. 16 
Sept. 23 
Scpr. 30 
Oct. 7 

Sept. 16 
Sept. 23 
Sept. 30 
Oct. 7 

Sept. 16 
sppt. 23 
Sept. 30 
Oct 7 

Sept. 16 

^ept 2:j 

Sept. JO 

Oct. 7 



18 









X 














h(l 






^ 


to 


3 


■^ 




" 






a 




E 


o 


tn 


(^IH 


_ cl 


^F^ 






rt <v 




§1 


p, 
o 
o 


s 


C3 

5 


•2 Oh 

s 


^ 


a; 


< 


3 



a Continued (ever. 



b One case of poliomyelitis was reported. 



Sanitary and Meteorological Notes. 



355 



Cases of Infectious Diseases under Treatment in Dublin 
Hospitals. 

Table II. exhibits the number of cases of certain infectious 
diseases treated in the Dubhu Hospitals during tlie week 
ended October 7, 1916, and the number under treatment at 
the close of each of the three preceding weeks. 









Table 


IL 










No. of Cases in Hospital 








Diseases 


at close of week ended 


Week ended Octobe 


r 7. 














No. 
















under 










No. 


Dis- 


Died 


treat- 




Sept. 16 


Sept. 23 


Sept. 30 


admitted 


charged 




ment 
at close 
of week 


Enteric Fevur 


60 


89 


105 


14 


12 


1 


106 


Tj^hus - 


— 


— 


— 


2 


— 


— 


2 


Small-pos - 


— 


— 


— 


— 


— 


— 


— 


Measles 


2 


1 


•2 


— 


1 


— 


I 


Scarlet Fever 


47 


51 


-to 


11 


6 


— 


54> 


Diphtheria - 


24 


17 


16 


11 


5 


3 


19 


Pneumonia - 


13 


12 


11 


7 


5 


— 


13 



* Exclusive of 15 patients in " Beneavin," the Convalescent Home of Cork 
Street Fever Hospital. 

From this Table it appears that the cases admitted to 
hospital during the week ended October 7, and the cases 
under treatment at its close, respectively, were as follow : — 
Enteric fever 14 and 106, typhus 2 and 2, measles and 
1; scarlet fever 11 and 54; and diphtheria 11 and 19. Seven 
cases of pneumonia were admitted during the week and 13 
remained under treatment at its close. Of the deaths in 
hospitals during the week 1 was from enteric fever, and 
3 were from diphtheria. 



356 Sanitary and Meteorological Notes. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, October 7, in 
96 large English towns (including London, in which the rate 
was 12.0), was equal to an average annual death-rate of 12.5 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland was 15.1 per 1,000, the rate for Glasgow 
being 15.7, and that for Edinburgh 14.7. 

Infectious Diseases in Edinburgh. 
The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for 
Edinburgh, with a copy of his Return of Infectious Diseases 
notified during the week ended October 7. From this 
Report it appears that of 63 cases notified, 20 were of scarlet 
fever, 18 of pulmonary tuberculosis, 4 of other forms of 
tuberculosis, 12 of diphtheria, 6 of eiysipelas, 2 of enteric 
fever and 1 of cerebro-spinal fever. Among the 372 cases 
of infectious diseases in hospital at the close of the week were 
142 of pulmonary tuberculosis, 111 of scarlet fever, 77 of 
diphtheria, 8 of measles, 7 of erysipelas, 6 of cerebro-spinal 
fever, 6 of enteric fever, 2 of whooping-cough, and 1 of puer- 
peral fever. 

Meteorology. 

Abstract of Observations made in the City of Dublin, Lat. 53° 20' 

N., Long. Q" 15' W.,for the Month of September, 1916. 

Mean Height of Barometer, - - .SO. 069 inches. 

Maximal Height of Barometer (9th, at 9 a.m.), 30.431 

MinimalHeightof Barometer (27th, at 9 p.m.), 29.629 „ 

Mean Dry-bulb Temperature, - - - 55.7°. 

Mean Wet-bulb TeiniJerature, - - 53.4°. 

Mean Dew-point Temperature, - - 51.4°. 

Mean Elastic Force (Tension) of Aqueous Vapour, .380 inch. 

Mean Humidity ... - 85.5 per cent. 

Highest Temperature in Shade (on 7tli), - 68.2°. 

Lowest Temperature in Shade (on 20th), - 43.1°. 
Lowest Temperature on Grass (Radiation) (20th), 38.9°. 

Mean Amount of Cloud, - - - 64.9 per cent. 

Rainfall (on 14 days), - - - - 2.141 inches. 

Greatest Daily Rainfall (on 2nd), - - 0.583 mch. 

General Directions of Wind, - - - W., N.W. 



Saiiifanj and Meteorological Notes. 357 

Remarks. 

Although heavy rainfalls occurred on the 2ud-3rd (0.713 inch) 
and 26th-27th (0.815 inch), September was a favourable month. 
The week ended Saturday, the 9th, was unsettled — at first with 
a relatively low, later with a very high, barometer (30.43 inches) 
on the 9th). The air was damp and the winds were light from 
points between W. and N. during this ]3eriod. The second week 
was generally fine, but the amount of cloud was large and fresh. 
W. and N.W. winds prevailed ; temperature also gave wny, 
the 14th in jjarticular being a cold day with the thermometer 
down to 45.9° at night, and not rising higher than 55.7° in the 
daytime. 

A blustermg, warm and rainy day ushered in the third week, 
in the course of which the fresh N.W. winds died down, finally 
giving place to a fight southerly air current. In the last Aveek 
(24th-30th) much cloud prevailed, except on Tuesday, the 
26th, which was a bright, Avarm day. A solar halo at 8 a.m. 
heralded a rainstorm, which began after midnight and lasted 
throughout the following day, the 27th. The last three days 
were fine but cloudy. 

In Dubfin the arithmetical mean temperature (56.8°) was 
0.9° above the average (55.9) ; the mean dry-bulb readings 
at 9 a.m. and 9 p.m. were 55.7°. In the fifty years ending 
with 1915, September was coldest in 1886 and 1892 (M. T. = 
53.0°), and warmest in 1865 (M. T. = 61.4°) and 1898 (M. T.= 
60.2°). In 1915 the M. T. was 57.2°. 

The mean height of the barometer was 30.069 inches, or 
0.159 inch above the corrected average value for September — 
namely, 29.910 inches. The mercury rose to 30.431 inches at 
9 a.m. of the 9th, and fell to 29.629 inches at 9 p.m. of the 
27th. The observed range of atmospheric pressure was, 
therefore, 0.802 inch. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 55.7°, or 5.9° 
below the value for August, 1916. Uusing the formula, i¥ean 
Temp. = Min. + {Max. — Min.) x .476, the mean tempera- 
ture was 56.6°, or 0.9° above the average mean temperature 
for September, calculated in the same way, in the thirty-five 
years, 1871-1905, inclusive (55.7°). The arithmetical mean of 
the maximal and minimal readings was 56.8°, compared with 



358 Sanitary and Meteorological Notes. 

a thirty-five years' average of 55.9°. The mean maximum was 
62.0° ; the mean minimum was 51.6°. On the 7th the ther- 
mometer in the screen rose to 68.2° — wind variable ; on the 
20th the temperature fell to 43.1°— wind, W.N.W. The 
minimum on the grass was 38.9° on the 20th. 

The rainfall was 2.141 inches on 14 days. The average 
rainfall for September in the thirty-five years, 1871-1905, 
inclusive, was 2.210 inches and the average number of rain- 
days was 15. In 1871 the rainfall was very large — 4.048 
inches on, however, only 13 days ; in 1913 it Avas 4.310 inches 
on 13 days ; in 1896 no less than 5.073 inches fell on 23 days, 
estabhshing a record rainfall for September. On the other hand, 
in 1865, only 0.056 mch was measured on but 3 days. In 1912 
,only 0.570 inch fell on 8 days, and in 1915, only 0.907 inch, but 
on as many as 16 days. 

High winds were noted on 8 days, but never attained the 
force of a gale. Fog occurred on the 5th, 6th, 26th and 27th. 
A solar halo was seen on the 26th and a lunar halo on the 10th. 
There were faint displays of aurora borealis on the nights of 
the 1st, 3rd and 28th. A flash of sheet hghtning was seen at 
9 p.m. of the 18th. 

The rainfall in Dubhn during the nine months ending 
September 30th amounted to 24.172 inches on 166 days, 
compared Avith 20.172 inches on 150 days in 1915, 15.827 
inches on 140 da^^s in 1914, 20.982 inches on 140 days in 1913, 
22.658 inches on 158 daj^s in 1912, 12.599 inches on 120 days 
in 1911, 25.108 inches on 159 days in 1910, only 10.968 inches 
on 112 daj-s ua 1887, and a thirty-five years' average of 20.160 
inches on 146 days. 



At the Normal Climatological Station in Trinity College, 
Dublin, Mr. T. IVlulock Bentle}' reports that the mean value of 
tlie readings of the dry-bulb thermometer at 9 a.m. and 9 p.m. 
was 57.1°. The arithmetical mean of the daily maxiiual and 
minimal tem[)eraturc was 57.0°. The screened thermometers 
rose to 70° on the 6th and fell to 43° on the 20th. On the 
loth the grass minimum was 36°. Rain fell on 12 days to 
the amount of 2.09 inches, the greatest fall in 24 hours being 
0.63 inch on tlie 2nd. The duration of briiiht sunshine 
according to the Campbell-Stokes recorder, was 68.6 hour^, 



Sanitary and Meteorological Notfs. 359 

of which 9.5 hours occurred on the lOth The mean daily 
duration of bright sunshine Avas only 2.3 hours. The mean 
earth temperatures were — at 1 ft.. 58.3° ; at 4 ft , 57.7°. 



At Ardffillan. Balbriggan, Co Dublin. 210 feet above 
sea-lev^el, Captain Edward Taylor, D.L., measured 1.83 inches 
of rain on 11 days, the rainfall being 0.13 inch below the 
average and the rain -days being 1 in defect. The total rainfall 
from January 1 amounts to 22.59 inches on 160 days. The 
year's rainfall so far is 1.94 inche.s above, and the rain-days 
are 24 above, the average. The maximal temperature in the 
shade was 69.8° on the 8th, the mininuim was 40.1^ on the 
20th. Within the past 20 years September was driest in 
1894, with a rainfall of 0.11 inch on only two days (the least 
in any month) ; wettest in 1913, the rainfall being 5.54 
inches on 12 da^^s. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dubhn, was 1.41 inches on 11 days, the greatest 
fall in 24 hours being 0.535 inch on the 2nd. Up to September 
30; the rainfaJl in 1916 amovnited to 21.255 inches on 158 days. 

Mr. J. Pilldngton reports that the rainfall at Stirhng, Clonee, 
Co. Meath (231 feet above sea-level), was 2.37 inches on 14 days. 
The largest amounts recorded in 24 hours were 0.71 inch on the 
27th and 0.51 inch on the 2nd. Since January 1st, 1916, the 
rainfall at Stirling amounts to 26.80 inches on 169 dkys. 

The rainfall recorded at the Ordnance Survey Orfice, Phoenix 
Park, was 2.215 inches on 11 days, the greatest measurement 
in 24 hours being 0.679 inch on the 27tli. The total amount 
of sunshine at this station was 77.4 hours, the most registered 
on anj^ one day being 10.2 hours on the 10th. 

At Cheeverstown Convalescent Home, Clondalkin, Co. 
Dublin, Miss Mary Love recorded a rainfall of 2.59 inches on 
11 days, the maximal fall in 24 hours bemg 0.96 inch on the 
28th. 

At 89 Anglesea Road, Donnybrook, Dublin, Mx. F. Dudley 
Jo3ntit registered 2.055 inches of rain on 11 days, the greatest 
fall in 24 hours being 0.660 inch on the 2nd. Up to September 
30, the rainfall at this station was 22.585 inches on 151 daj^s. 

Dr. Arthur S. Goff reports that at Belfort House, Dundrum, 
Co. Dubhn, the rainfall for the month was 2.52 inches. 

At iVIarino, Kilhney, Co. Dubhn, Mr. Wm. J. M'Cabe, the 



360 Sanitanj and Meteorological Notes. 

observer for the Right Hon. Laurence Waldron, D.L., 
recorded a rainfall of 2.15 inches on 11 days, the largest 
measurement in 24 hours being 0.91 inch on the 1st. On the 
27th, 0.56 inch fell. The average September rainfall at 
Cloneevin, KiUine3% in 24 years (1885-1908) was 1.961 inches 
on 12.9 days. 

Dr. J. H. M. Armstrong, M.B., reports that at Coolagad, 
Greystones, Co. Wicklow, the rainfall was 2.88 inches on 
13 days. The heaviest fall in 24 hours was 1.32 inches on the 
2nd. At Coolagad the rainfall since January 1st, 1916, has 
been 29.42 inches on 164 days. Temperature in the shade 
ranged between 69° on the 12th and 46° on the 14th and 19th. 
Sheet lightning occurred on the N.E. horizon at 7 20 p.m. 
on the 26th. 

At Auburn, Greystones, Mrs. Sydney O'Sullivan recorded a 
rainfall of 2.58 inches on 13 days. The greatest rainfall in 
24 hours was 1.27 inches on the 2nd. 

Dr. F. O'B. Kenned};^, Resident Medical Officer, reports that 
at the Royal National Hospital for Consumption for Ireland, 
Newcastle, Co. Wicklow, rain fell to the amount of 2.38 inches 
on 13 days, the heaviest rainfall in 24 hours being 1.22 inches 
on the 2nd The screened thermometers rose to 68° on the 
7th, and fell to 44° on the 15th. The ]nean maximal tem- 
perature was 61.7°, the mean minimum 50.6°, and the 
arithmetical mean temperature 56.2°. 

The Rev. Canon Arthur Wilson returns the rainfall at the 
Rectory, DunmanAvay, Co. Cork, at 1.35 inches on 14 days, 
the heaviest fall in 24 hours being 0.72 inch on the 25th. 
The total fall in the completed 9 months of 1916 has been 
36.05 inches, or 0.94 inch less than the average of the same 
period in 6 years (36.99 inches). There was thunder, with 
lightning and heavy rain, on the afternoon of Monday, the 
25th ; and sheet lightning was seen on the night of Tuesday, 
the 26th. It was a very fine, warm montli ; but many nights 
and early mornings were " misty," "svith drizzle, which 
accounts for tlie large number of rain-days in spite of the small 
total rainfall. 



LITERAEY NOTE. 

T)iK Sixth Edition of Hutchison and Ivainy's "Clinical 
Methods" is announced for early publication by tlic House 
of CasscH, La Belle Sauvage, London, I'j.C. 




By !, 



\F.(/!/iir i>f' ^' fn's/i Life." 



ROBERT LAFAYETTE SWAN. 
Born April 27, 1843. Died November 4, I9I6. 



THE DUBLIN JOURNAL 



OF 



MEDICAL SCIENCE. 

DECEMBER 1, 1916. 

PART I. 
OPJGINAL COMMUNICATIONS. 



Art. XVTT. — E.rpcricncrfi of Renal Surgenj.^ By Lt.- 
CoL. \A^iLLTAM Taylor, R.A.M.C, M.B. Univ. Diibl. ; 
President of the Royal Colleoe of Suroeons in Ireland : 
Siu'geon to the Meath Hospital and County Dublin 
Infirmary. 

When going over my renal cases I found that T had per- 
formed l^f> o]")erations upon 128 patients. The operations 
consisted of 92 fixations, 26 total nephrectomies, 1 partial 
nephrectomy and 19 nephrotomies. Of the 19 nephro- 
tomies, 5 were merely exploratory, and 14 were for the 
removal of calculi (in the case of one patient calculi were 
removed from both kidneys). There was one death. This 
death occurred in the case of a gentleman whose left kidney 
I removed for hydronephrosis. There was nothing whatever 
difficult about the operation, which was completed in less 
than half-an-hour. The drainage tube was removed on 
the morning of the second day, and the wound was soundly 
healed at the end of a week. On the tenth day I allowed 
the patient to sit up, on the thirteenth day he was walking 

' Read before the Section of Surgery in the Royal Academy of 
Medicine in Ireland on Friday, October 27, 1916. 

VOL. CXLII. — NO. 540, THTRP SERIES. 2d 



362 Experiences of RennJ Surgery. 

about, and had arranged to return home two days later. 
There had never been any fever nor increased rapidity of 
the pulse. Having been up for several hours and feeling — 
to use his own expression — in the best of spirits, he de- 
cided to walk round his room a few times after his supper, 
before going into bed for the night. \Yhether he tried to 
do this T do not know. As the nurse left the room to get 
a hot jar for his bed, she heard him call, and returned 
immediately to find him sitting on a chair with his face 
twitching, and, as she thought, dying. In five minutes 
he was dead. What the cause of his death was it is hard 
to state, as he did not complain of any sudden pain, and 
did not appear to have any difficulty in breathing. 

With regard to the different groups of cases, there were 
92 fixations in 83 patients, 9 being double nephropexies. 
The operation of nephropexy is not performed by any 
means so frequently now as it was some eight or ten years 
ago, and I think rightly so. It is seldom that a movable 
kidney which is not actually causing definite renal patho- 
logical changes gives rise to symptoms which can be 
unhesitatingly attributed to its mobility, and unless the 
patient's sym]:)toms can be definitely ascribed to a movable 
kidney, I do not think any operation should be undertaken, 
l^ut, if treatment for the movable kidney is indicated, in 
my o]~)inion the operation of nephropexy is certainly pre- 
ferable 1o the use of a l)elt. Of the 19 nephrotomies, 
jx^rfornied upon 18 ])atients, 14 were for the removal of 
calculi On one |)atient calculi were removed from 
holh kidneys), one was an ex])I()ration of the left 
kidney for very severe lia-morrhage. The remaining nephro- 
tomies were undertaken in cases where the most typical 
syniploms of stone were present, but the explorations 
were negative. The ha-maturia case was that of a lady 
whom 1 saw in consultation some six or seven years ago. 
l^^or twenly-foiu' hours befoi'e 1 was called in she had 
been passing hirge (pianlities of blood, (he ha-niori'liage 
(•onMn;4 on (|iiit(' su(1d(>nly as she was going about her 
household diilics. When I saw her the bleeding was very 



By Lt.-Col. W. Taylor, P. R. C.S.I. 303 

profuse, and I had lier at once removed to hospital, where 
Dr. Cecil Smyly kindly cystoscoped her. It was with 
difficulty he could get the l)ladder sufficiently clear of 
blood to be able to see distinctly, but, after some time one 
could see the bleeding coming profusely in strong jets 
from the left ureter. Morphine and lactate of calcium 
were given, but without effect, and, as next day the lady 
was still bleeding freely, and as constitutional evidences 
of the loss of blood were becoming manifest, I explored 
the left kidney. On withdrawing the kidney from the 
lumbar incision nothing abnormal was to be seen or felt. 
The kidney was then split o])en from pole to pole, but no 
gross pathological lesion could be detected to account for 
the bleeding ; there were no signs of new growth, nor signs 
of tubercle, and there was no stone. In every respect to 
the naked eye it was a perfectly normal kidney. The 
surfaces were sutured together by mattrass sutures of cat- 
gut. The kidney was then fixed by gauze packing and 
the wound closed. In three days the ha:'morrhage had 
ceased, and on the fourth day the urine appeared normal. 
She was able to leave hospital in two and a half weeks, and, 
so far as I know, she has never had any recurrence of 
bleeding. What is the pathology of this form of ha^-mor- 
rhage? With regard to the other exploratory nephrotomies 
I am not ([uite sure what the pathology was, but I believe 
three were cases of pyelitis. One was most probably 
a chronic interstitial nephritis. The former recovered com- 
pletely, the latter died from ura^mic convulsions four years 
subsequently. Of the nephrectomies 26 were complete 
nephrectomies and one was partial. The latter was per- 
formed for the removal of a tumour which seemed to be 
growing from the lower ]wle of the left kidney in the 
case of a lady aged about 43 years. The tumour was about 
as large as the closed fist, and on section after the opera- 
tion seemed to be of a fibro-li]')omatous character. It was 
apparently intimately connected with the lower i)ole of 
the kidney whicli was removed witVi it, and the patient 
has since enjoyed good health. Of the 2.5 complete 



364 Expcrienccfi of RcnaJ Surgery. 

nephrectomies, 12 were performed for tuberculosis, 3 were 
performed for hyper-nephroma, and one for a new growth, 
believed to be hyper-nephroma, but the nature of which 
was not definitely settled ; 4 were performed for hydro- 
nephrosis, and 6 for extensive pyonephrosis. The opera- 
tion of nephrectomy may be one of the easiest and simplest 
of surgical procedures, or, on the other hand, it may be 
one of the most difficult and trying operations that a 
surgeon could encounter, and may tax his ingenuity and 
resource to the uttermost. The difficulty of nephrectomy 
depends mainly upon the extent of the adhesions, and 
it is in determining whether these adhesions should be 
completely separated and the entire kidney and its capsule 
removed, that sound judgment is required. My feeling 
is that the majority of surgeons do not recognise the great 
ease and safety with which sub-capsular nephrectomy can 
be performed. Unless in case of new growth, and even 
in some of them, the adhesions are due to peri-nephritis 
which brings the capsule of the kidney, the peri-nephritic 
tissues and all the surrounding" structures into one in- 
separable mass. T believe any competent experienced 
surgeon ought to be able to determine within a very few 
minutes after exposing tlie kidney whether he can, with 
any prospect of success and with safety to the patient, 
separate the adhesions which are binding the diseased 
kidney to the surrounding structures. Tf the disease for 
which the operation is undertaken is malignant, every 
oH'ort must be made to remove the kidney and its capsule 
completely. Tf in other cases it is obvious that great 
difficulty is to l)e exjierienced, and much time expended, 
in the separation of adhesions whereby a considerable 
amoinit of blood will be lost and shock thereby intensified, 
I feel satisfied that sub-ca])sular enucleation should be the 
operation selected. T have several times removed kidneys 
by sub-ca])sulnr enucleation within a lew uiiinites, with- 
out the loss of uioic than a ('ou))Ie of ounces of blood, and 
with no appi'eciable shock, in which cases T am convinced 
T could no! ha\(' reuioved the entire ki(lne\ without a 



By Lt.-Col. W. Tam^oj!, I'. J;. C.S.I. 3G5 

tedious operation, without the loss of a considerable amount 
of blood, and with very severe shock. 1 know of a case 
in which two hours were expended in attempting to 
se})arate adliesions in order to extirpate a kidney for cal- 
culous pyoneplnosis, but without success. 

My experience convinces me that the operation of sub- 
capsuUir nephrectomy is practically devoid of danger. On 
one occasion J was coinpelled to adopt this method of 
removing the kidney in a case of old-standing tuberculous 
disease associated with secondary pyogenic infection pro- 
ducing an enormous pyonephrosis. The kidney was so 
fixed that it could not be moved. Sub-capsular nephrec- 
tomy was accomplished within a very short time, and 
beyond the fact that a sinus persisted in the lumbar 
region for about two months, there was no further trouble, 
and the patient is now, six years after the operation, in 
perfect health. It is with tuberculosis of the kidney, I 
take it, that physicians are most concerned. Urinary 
tuberculosis is almost invariably primarily situated in the 
kidney. Vesical tuberculosis is always secondary to ex- 
tension from the kidney or epididymis. The diagnosis of 
renal tuberculosis is not always easy. The early symptoms 
are frequency of micturition, htrmaturia, pain, and pyuria, 
and generally they appear in that order. Primary reu'^i 
tuberculosis should be suspected, and very carefully repeat' d 
examinations of the urine should be made with that vie\v 
in mind, in all cases in which diurnal frequency of mic- 
turition seems to come on without otiier obvious cause, 
and persists for some time, more especially if associated 
with pus. Repeated examinations should be made for 
tubercle bacilli in the centrifuged urinary deposit, and 
cystoscopic examination should be made by a skilled 
cystoscopist. The presence of acid-fast bacilli in the urine 
is not always conclusive proof of the presence of tubercle 
in the kidney. Even the presence of acid-fast bacilli in a 
catheter s])ecimen is not absolutely conclusive. I know 
of some cases in which acid-fast bacilli were found in a 
catheter specimen, and yet the subsequent course proved 



366 Experiences of Renal Suraenj. 

that the trouble was not tuberculous. Smegma bacilli 
may easily contaminate a catheter specimen if great care 
is not taken in passing the catheter, even after careful 
washing of the parts, and I must say I do not see wdiy 
smegma bacilli might not occasionally pass along the 
female urethra into the bladder and therein produce irri- 
tation, and so cause frequency of micturition. In a doubtful 
case some of the centrifuged urinary deposit should be 
injected into a guinea-pig. 

I have no faith whatever in von Pirquet's test, and I 
have no experience of Calmette's test. The diagnosis 
once established, nephrectomy in the early stage of renal 
tuberculosis is the only method of treatment by which 
a cure can be assured. It is indicated whenever the 
diagnosis of uncomplicated unilateral renal tuberculosis 
is made. Nephrectomy of the primarily diseased kidney 
may still be performed in some cases even in the presence 
of secondary involvement of the other kidney, provided 
that the functional activity of this secondarily affected 
kidney is satisfactory. In such a case the operation is 
undertaken with the object of diminishing the toxicmia. 
Nephrectomy is contra-indicated in advanced disease in 
other organs, such as the lungs, peritoneum, spine, or 
joints, as well as in a generally enfeebled state of the 
patient, and in any case in which the functional activity 
of the other kidney is not considered equal to the task 
of maintaining life. It may be said that cases of renal 
tuberculosis have recovered under treatment by tuber- 
cubu and other niedieal methods. That such is the case 
i d(j not for a iiioiiient doubt. In fact, 1 know of two 
such cases, but still, cure by such treatment is exceptional 
and cannot he iclicd upon. If icnal tuberculosis did frc- 
(juently get well without operation it would be reasonable 
to expect thiit \\i' should find evidences of healed tuber- 
culous lesions in kidneys at pufii-iiiorieni oxamiiuitions, 
and yet I. am not aware that many, if indeotl, any, such 
cases have ever been recordetl. That [)ermanent recovery 
fioni renal t uhciculosis without sur-^ieal removal of the 



By Lt.-C'ol. \V. TavloI!, P.lv.Cl.S.l. 307 

diseased kidney is exceptional, and not to be relied upon, 
is borne out by the report of Wildbolz at the last German 
Congress of Urology. He collected 316 cases of renal tuber- 
culosis treated in Switzerland, the place above all others 
supposed to have climatic conditions exceptionally 
favourable for the treatment of all tuberculous afi'ections. 
As well as T can remember only 10 per cent, of the patients 
were alive 'more than five years after the onset of the 
disease, and in only five per cent, had all symptoms dis- 
appeared over five years. The results of surgical treatment 
are certainly more satisfactory, and are followed by a 
cure in the majority of cases operated upon. Since the 
introduction of modern methods of diagnosis of renal 
function the immediate mortality of nephrectomy for 
tuberculosis has fallen to less than three per cent. In one 
large clinique the actual mortality was 2.85 per cent., 
and in the Mayo Clinic, where over '200 cases were 
operated upon, the mortality was 2.9 per cent. 

Of the deaths that occur at a later date from tubercu- 
losis in other parts, or from complications which were 
j)resent at the time of operation, fully 60 per cent, take 
place within a year. Of my cases, so far as I can ascertain 
ten patients are still alive, one died of extensive secondary 
tuberculosis three years subsequent to operation. Tiie 
other death, which has recently occurred, was that of 
a young girl whose right kidney I removed nine years 
ago for tuberculosis, at the age of 17 years. At the time of 
operation there was considerable bladder infection, and 
we believed the left kidney was secondarily involved, but 
still functionating satisfactorily. The bladder ulceration 
never healed, in spite of tuberculin and local treatment, 
but this T attribute to the fact that the other kidney was 
involved, thereby continually infecting the bladder, and 
that the patient's resistant power to tuberculous infection 
was extremely low. Her family history was exceedingly 
bad. One member died of tubercular meningitis, one 
died of tubercular peritonitis, one of phthisis, and one 
had tuberculosis of the knee-joint, while the father had 



368 Experiences of Ucnal Surycrij. 

also died of tuberculosis. This girl died during the past 
year. The remaining ten cases are aUve and well. Of 
c;)urse, no one supposes for a moment that nephrectomy 
could possibly increase the resistant })ower of the patient 
or do other than remove the active source of infection. 
In short, then, everything points to the conchision that 
nephrectomy Jiolds out the only hope of assiu'ed cure for 
renal tuberculosis, and the sooner tlie operation is per- 
formed after the condition is diagnosticated the better. 
With regard to nephrectomy for hyper-nephroma there is 
hltle to say. One case is of interest from a clinical point 
of view. It was that of a gentleman about 56 years of age. 
Eighteen years before I saw him he noticed that for two 
days there seemed to be some blood in his urine. It ap- 
l^eared without cause, so far as he knew, and disappeared 
without treatment. Twelve months before coming under 
my care he got an attack of pneumonia, which terminated 
in the expectoration of a considerable quantity of pus and 
blood. F^very week or ten days he became feverish, felt 
ill, then had a fit of coughing and ex])ectorated a quantity 
of pus and blood, varying in amoimt from a few ounces 
to half a pint or more. This condition continued from 
October, 1908, until I saw him in November, 1909. At 
that time there was a swelling extending downwards from 
the sixth ril), as far as the iliac crest on the right side. 
The opj)osite side of the chest in comparison seemed 
flattened. The diagnosis suggested was a hypophrenic 
abscess communicaling with the lung, and the bulging 
that extended downwards was taken lo l)e the displaced 
livei". It was seen by sevei'al of my colleagues, and they 
all coiiclridetl that the case was either an hepatic abscess, 
or a light hypophrenic abcess. A-ray photographs and 
the use of the .r-ray screen gave us no further information. 
A few |)us cells were found in tin- luiue. Exploratory 
incisi(jn showed us that tin- li\('r was perfectly normal, 
both in position and si/c, and that the tumour was really 
the light kidney. As a fi'ee counnunical ion existed between 
the l<i(lne\ and Iuul;. it was obvious thai it wcjuld not be 



r^y Lt.-Col. W. Tayloh, r.u.c.s.i. ;-3G9 

jiulieious to attempt to perform nephrectomy- Conse- 
quently, alter closin<^" the exj)loratory incision tlie tumour 
was ex[)osed through the loin, and the su|)|)uratinj4 mass 
was incised. A considerable quantity of broken-down 
tissue and ))us escaped, and a quantity was further scooped 
out with the hand until liii'inorrhaiie became so free that 
several la[)arotomy sponj^es had to be ])acked into the 
cavity to stop the bleeding. A moderate amount of blood 
was expectorated for two or three days, after wiiich the 
expectoration gradually ceased. The gauze s[)onges were 
removed day by day, and in the course of some four or 
five weeks the man was able to walk about free fronj 
cough and expectoration. Two months subsequently, as 
there had been no pulmonary trouble in the meantime, 
and as the man seemed in good health with nothing but 
a small sinus in his loin, 1 decided to try and extirpate 
the kidney. This was accordingly done, and was by no 
means easy of accomplishment as the adhesions were con- 
siderable, but recovery was complete, and the patient is 
now, seven years after the operation, in perfect health- 
The tumour after removal weighed over 8 i)ounds, and was 
a typical hyper-nephroma, growing mainly from the upper 
poles of the kidney. 

Taking all my cases together there were 138 renal 
operations with one death, or taking them in grou])S there 
were 9i2 fixations without any mortality ; 19 nephrotomies 
without mortality ; 9 nephrectomies for calculous hydro- 
ne])hrosis, calcidous pyonephrosis, or pyonephrosis with- 
out calculi, with one death ; 13 nephrectomies for tuber- 
culous disease without a death ; 4 nephrectomies for tumour 
and one partial nephrectomy for tumour all followed by 
complete recovery. The conclusions 1 am inclined to de- 
duce from my experience of these cases are : — 

1. That where movable kidney is unquestionably the 
cause of the symptoms complained of by a ])atient or, 
when the mobility is leading to actual renal jxithological 
changes, active treatment is demanded, and 1 believe the 
operation of nephropexy is undoubtedly preferable to the 



370 Presidential Address. 

use of any niechanical a[)paratus. The operation is one 
practically devoid of risk. 

2- That calculi once diagnosticated should be removed 
by operation without delay, otherwise destruction of the 
kidney will inevitably occur sooner or later. The risk of 
the operation of nephrectomy, which will then probably 
be necessary is considerably higher than that of nephro- 
tomy. It may be taken that the mortality following 
nephrotomy in aseptic cases is not more than '2 per 
cent., whereas the mortality of nephrectomy for calculous 
disease is about 17 or 18 per cent. 

3. That tuberculosis of the kidney is best treated by 
nephrectomy performed as soon as possible after the 
diagnosis has been effected, and if possible before secondary 
infections have occurred elsewhere. 

4. That the prognosis of nephrectomy for hyper- 
nephroma, if performed before secondary deposits have 
occurred in other parts, is exceedingly favourable. 

5. That partial nephrectomy is an operation of very 
limited usefulness, but that under certain conditions it is 
quite a safe and satisfactory procediu'e. 



Art. X\in.-—Presi(le}ttial Address.-^^ By Henry ('. 
Deury, M.D. Dubl. ; E.R.C'.P.l., Physician to Sir 
Patrick Dun's Hospital, Dublin; President of the 
Section of Medicine in the Eoyal Academy of Medicine 
in Ireland. 

1 i''ii;sT wish to express my thanks foi' the honour you 
have done me by electing mc i'residonl of the Medical 
Section of the ]\oyal Academy of Medicine in Ireland. 

I appreciate the position very highly, foi' in my own 
medical lifetime I have seen this Chair occupied by those 
alone, whom I haw looked upon with respect and honour, 
my teachers, and my friends, in the roreiiiost ranks t)f the 
profession in this eoimtry. Some cynic amongst us may 

• An Introductory Address to the Section of Medicine in the Royal 
Academy of Medicine in Ireland, delivered on Friday, November 3, 1916. 



By Di;. II FAUV C. Dl!^l:^. 371 

say, ■' Oh, you have been elected to the position because 
there was very httle choice." Unfortunately, our cynic is 
quite truthful in this, ;uul I acknowledge it with regret. 1 
have attended the meetings of the Section with fair regu- 
larity ever since T was (jiialitied, for 1 felt that I not only 
received benefit from them, hut I considered it a duty to 
show some interest in this, our representative gathering 
of the Profession in Ireland. 1 fear there are too many 
who do not take, or do not act on this view, and hence 
the supposed remark of our cynic is too true. 1 see little 
else for which 1 merit the position in which you have 
kindly placed me. 

I think we nutst confess that the meetings of our 
Section are not attended as they should be. 1 hope tluit 
during my year of oftice we may improve in this matter, 
and would, tlierefore, urge on all who are present, that 
each will make a personal endeavour, not only to come 
himself to the sectional njeetings, but to induce some one 
else to come also. ^^ hy not ask a medical friend in the 
suburbs to join you at dinner, and come afterwards to the 
meeting of the Academy? This, in itself, will be a welcome 
improvement, it will be an encouragement to those wlio 
pre[)are and bring down connnunications, and stinudate 
others to do the same. Incidentally it may induce some 
to join our Society. Let each one also cast about for some 
subjects to bring forward for information and discussion. 
There is no necessity for these to be out of the way in 
either rarity or prolixity. The subjects of everyday prac- 
tice afford ample material for enlightenment, and brevity 
in their presentation will add to their interest, and stimu- 
late and give time for their discussion, which will be 
within the scope of all. 

In thinking how we can make oiu' meetings more 
popular — tluit is, more successful — one begins by asking : 
Why are they not more ])opular? fn this connection some 
impleasant ideas arise which one would hope are not 
correct. Are we getting too self-indulgent ; too comfort- 
able after dinner to come out to our Medical Societ}' ; 
allowing comfort and laziness to overcome our duty to 



37"2 Presidential Address. 

ourselves, our Academy and our professional friends who 
have prepared subjects for discussion? We almost tear 
there is some truth in this idea. 

Another unpleasant tliought suggests itself, and 1 fear 
very much there is some truth in it also. Are we becoming" 
less professional and more mercenary? 1 mean, are we, 
as a body, getting to think less wliat we can make of our 
profession, and more wiiat we can make out of it '^ If 
there is a tendency, as we read the notice paper of the 
meetings, to think less whether we can learn anything 
to help us in our work, or give the benefit of our experiencie 
to others, and so help them; and subconsciously to think 
more, will it pay me? I cannot get into the limelight 
beft)re the public here, this will not bring grist to the mill, 
so it is no use to me. If there is any truth whatever in it, 
this is a deplorable condition of affairs. I am sure there 
have always been in the profession individuals, whose sole 
idea was to make it [)ay — they are mere traders, not pro- 
fessional men. 1 do not refer to tliese, but to the fear that 
the profession as a whole is gradually becoming infected 
with this s})irit. 

That this was not the spirit of the profession here 50 to 
lUO years ago, is jiroved by the ])roud ])osition to which 
they raised it in the eyes of contemporaries and later 
generations, the world over. They won this ju'oud position 
not by taking their ease in the evening and gathering in 
money by day — but by starting Societies such as this — 
indeed, the parents of this — by which they might sharpen 
each otliers wits, glean from each others experience, 
vie with eacli other in observation and hnestigation, and 
enlighten one another by gathering together scattered 
threads and weaving them into an organised fabric. This 
is tlie true professional spirit. J3ut if anyone harps back 
on the old degrading cry, does it |)ay? I lie answer comes 
with no imcei'tain voice, ^'es ! it pays. Though it may 
not be given to any of iis to he r(>\('r(Ml by lutui'e genera- 
tions, to he honoured lliroiigh lar (hstnnt countries, to 
stand in imperishable nuuble, aniongst our successors in 



By Dr. Henry C. Drury. 373 

tlie flesh, all down the years — still, there are compensa- 
tions tor us. ^^'here can yon get anything for i'. s. d. 
comparable to the pleasure, the satisfaction, the com- 
panionship, the healtliy unselfish rivalry, to be met with 
in your own professional circle — not in the narrow cliques 
of it — but in the big circle which embraces all members, 
witli all their diverse cliaracteristics, and all their various 
aims? Cast your mind back and around you, and see if 
it is not the men who have taken most advantage of these 
opportunities, who, if not the wealthiest, liave been the 
leaders of the j^rofession, its representatives most respected 
both by ourselves, and by their fellow-citizens at large. 
This is payment which cannot be reckoned in gold. 

If you agree with me in this line of thought, and act 
on it, our meetings will certainly improve. 

There is still another reason, in my opinion, why our 
meetings are not better supported. The menu has a 
tendency to remain heavy and monotonous. We want 
occasionally an entre'^e, savoury, and sw^eets, and if the 
" trifle " is sometimes " seasoned " so highly that it 
causes such excitement that outsiders might — quite 
erroneously — describe it as a " row," it may attract other 
outsiders for the next night, in expectation of another 
"row" — for who can withstand the attraction of even a 
dog fight ! 

We must endeavour to attract, not only men occupying 
hospital posts, but other less fortunate practitioners. 
These are the very men who should benefit most by our 
meetings, and who would benefit us greatly by giving the 
results of their own shrewd observation, and very varied 
experiences. We nnist admit that w^e do not attract these 
men, and ask ourselves — why? If we can agree as to 
the reason, we are bound to apply the remedy. We have 
endeavoured to popularise the meetings by holding" them 
in a smaller room, and by allowing smoking — with, how- 
ever, scant success. The large half-empty hall, and more 
formal atmosphere unclouded by tobacco smoke, were not, 
therefore, the sole reas(Mis for non-success. Can it be that 
the material we offer dot>s no! attract? I fear so. 



374 Presidential Address. 

It is necessary, therefore right and proper, that papers 
deahng with recent advances in theory and practice, and 
original investigations of cases or classes of cases, should 
he brought forward here, and the more elaborate the care 
i)estowed on them, the more valuable they will be, and 
the more highly should we esteem them. 

In presenting such at a meeting some condensation is 
not only allowable but advisable, the main facts then 
appearing more clearly, and being more likely to be 
grasped by the hearers than if they are shrouded in a 
mass of detail. Such details should be found in the pub- 
lished transactions, where they can be studied and com- 
pared at leisure, by all interested in the subject at home 
or abroad — but their recital at a meeting serves no useful 
purpose, they cannot be carried in the mind of any ordinary 
person, so they only confuse and tire an audience, and 
take up time which might more profital^ly be devoted to 
discussion. 

Let us take an instance — and in doing so T must assure 
you that T have no particular example in mind — it is 
merely a sample of the group of highly technical papers 
of which we hope to have several. Tt is of the utmost im- 
portance that the changes in the blood in a case of Leu- 
cocythemia, under treatment, should be accurately noted 
and recorded, but the recital of these changes in detail, 
observed day by day, or week by week, will convey far 
U'ss to a listening audience, than a short sunnnary of 
i]\c I'csiilts, and if such recitals are of frecpient occurrence 
llicy will make men prefer their fireside to our meeting. 
Il must be remembered that luost of the audience cannot 
carry out these iuvestigations, but they can judge the 
residts, and they want to do so, and to adopt or reject 
(•(M'tain treatments on those results. Our ])apers should 
he as brief as is consistent with thoroughness. A long 
pnpcr is not necessarily a good |);i|)iM', and it is a jioor 
cohiplinient to the intelligene(> of his audi(Mice for the 
iiiithor lotliiid\' th;it tliev wih l)e impressed hy its length. 

I e;in reciill |);ipers i'e;i(l hel'ore this section, which oc- 



By Dr. Henry C. Drury. 375 

cupied the whole time of the meeting, but which held the 
attention of every listener all through, because of their 
varied and absorbing interest. Others who occujiied a 
like period of time, in which one certain form of treatment 
was introduced by an elaborate prologue, brightened only 
by gymnastic exercises over unpronounceable names, in- 
troduced for the purpose of impressing everyone, but failing 
to impress anyone; followed by a long procession of cases, 
detailingwith iteration and reiteration the wondrous results 
of treatment obtained in each and all. The whole thing a 
really competent man would have disposed of in five 
minutes. Such papers ))ian have a vivifying effect on the 
author, but do have a deadening effect on our Society. T 
think that our Council should have some control over such 
cases. Authors of papers should be required to state f^x- 
plicitly to the Secretary how long they required for their 
papers. The Council should then discriminate, and allot to 
men of the first kind the wliole time they recpiire ; and to 
men of the second kind, time sut^cient, but no more, for 
a succinct statement of their case. The Chairman of the 
evening would then be responsible for curtailing exuber- 
ance or giving latitude to merit. 

Besides the technical jiapers we must have others less 
technical, less elaborate, dealing with everyday cases, 
illustrating difficulties, suggesting lines of treatment or 
investigation, and so promoting discussion. Papers of this 
kind can be prepared by anyone, no matter how busy 
he is, no matter whether he has a hospital or not. They 
are suggested in our daily work, thought over as we go 
to and fro in it, and jotted down in the spare intervals of 
it. They will benefit the writer, attract and interest the 
hearers. They will widen the circle of thought, clear up 
some difficulties, perhaps open up fresh ones — perchance 
one of them may mark an epoch. These will prove the 
savouries and sweets of our menu. Well seasoned trifles 
will occasionally appear and ]n'ovoke much entertainment. 
Discussion will be more frequent — even more lively, and 
tliere will be no need to go into the highways and ditches 
to compel men to come in that our house may be full. 



876 Prcftidrntial Addrcfifi. 

What T wish to drive liome is, that it is not necessary 
to wait till some extraordinary or rare case comes into 
our practice, to enable us to make a communication here. 
Abundant material is to be found in every man's practice 
it he has eyes to see, the mind to appreciate, and the 
wish to improve on it. 

Up to the' year 18"27, every medical man saw plenty of 
cases of dropsy, and most of them were satisfied that it 
was just dropsy, and that was all about it. But Kichard 
Bright saw in this common and apparently uninteresting 
condition, much food for thought, and the thinking in- 
spired investigation, with the result that he made an 
epoch in the history of Medicine and insured for himself 
an honoured name down through future generations, by 
his paper an Nephritis. 

Eighty-nine years have elapsed since Bright introduced 
this new-old disease to the profession ; yet how much 
further on are we since Bright laid down his pen nearly 
ninety years ago? The sim])licity of his method of 
diagnosis, and the very common occurrence of the disease 
which it revealed, would almost seem to have impeded 
investigation. Just as the older practitioners were con- 
tent with the diagnosis of Dropsy, now we seem to be 
content with the diagnosis of l^i'ight's Disease, and there 
is nothing more to l)e said about it. Even our hospital 
class will see nothing more than the diagnosis and very 
little in that, for when we try to talk to them about the 
disease they think they can manage the " parenchyma- 
tf)us " and " inlerstitial " shibboleth, and that this is all 
they require. They would remain with us if we brought 
them to a case of Myasthenia gravis, l)u( not having some- 
thing strange sounding' at hand, hnl only some "conunon" 
case they slip away for the )n()re intellectual entertain- 
ment of a surgeon am])utating a little finger — thus showing 
1 li(> real way to cure. 

Ijast session one* of oui' senior members, Dr. Walter 
Smith, did not lliink- il IxMicntli liini to ponder over and 
invcsligatc the nid subject of diopsy, and lie IrcaltMl 



By Dt^. Henry C. Drfry. 377 

us with an illiiiiiinatinjji and scholarly paper, pregnant 
with ideas, which inay be fruitful in clearing up many 
perplexing questions. But though he did not lay down 
any definite conclusions, I consider it was one of the most 
important papers we have had for a very long time. 

Again, T inquire, how uuich has our knowledge really 
advanced on the subject of chronic nephritis since Bright's 
day? In minor details, something. In general principles, 
little. 

The true aim of medical treatment is, prevention, and 
tiiis entails a knowledge of the cause. If we get ague, we 
take quinine and find relief; this was, till a few years ago, 
purely empirical treatment, and is now only palliative, 
because the cause has been found. We kill the moscjuito 
or prevent it biting us, thus curing by prevention — a good 
and true treatment. 

What about the cause of Bright's disease? and what 
investigations are made to elucidate it? Nephritis glides 
stealthily through our communities of rich and poor alike, 
with relentless assiduity. It claims its victims without 
sign or warning, makes sure of a firm hold before it makes 
itself felt, and then, in spite of our best endeavour, holds 
on still. It counts its victims by the thousand. 

The Registrar-General has kindly furnished me with 
the following figures. In 1912 chronic nephritis was given 
as the "cause of death," in the Dublin Registration district 
alone, in 209 cases, or 2.39 per cent, of the total deaths 
in that district, that is, 0.52 per 1,000 of the estimated 
|io]^ulation of the district. In 1913 the figures were 253 
deaths, 2.92 per cent, of total deaths, and 0.63 per 1,000 
of population. These large figures do not, to my mind, 
represent anything like the mortality due to this disease, 
many deaths, such as apoplexy and other conditions, being 
due to it. 

What are we doing to stop this terrible mortality, this 
fearful scourge? 

If i1 came u]ion us with a shout, striking l)ut one here 

2 E 



378 Presidential Address. 

this week, another there next week, and so on, laying 
them out in ghastly disfigurement, or racking pain, finisli- 
ing them off in as many hours or days, with as great 
certainty as it reahy does in years, it would arrest the 
nation's attention, provoke its horror, and arouse it to 
demand that something more should be done than we 
are content with now. Why should we wait till we are 
spurred or shamed into action? 

Yet, how far have we got on with the preliminaries of 
the fight? What do we know of the cause? Practically 
nothing. Gout, lead, alcohol, syphilis, the acute exan- 
thems — these sum the causes we know of. But how do 
the}' act? x-Ml are so dissimilar, and how few, how very 
few of our cases can be accounted for by these most crude 
causes? But how very many, none of these will explain 
at all. 

Would it not be a splendid achievement and a triumph 
for our Academy if one of our members, through careful 
investigation, found a cause for many of these unexplainel 
cases ; while another worked out how this cause acted, and 
a third proved how it could be avoided? All the steps 
which lead to these results having been submitted to the 
friendly and helpful criticism of our most advanced and 
experienced members, before being given to the profession 
in general. 

Tn this mysterious disease, also consider its protean 
and conflicting forms; its distressing symptoms here, and 
its unassuming mastery there; its tai'dy progress or its 
sometime hghtning stroke; and its cynical indifference to 
our endeavours to curb its general elTects or control its 
special and varied manifestations. 

f have only endeavoured, by taking this example of a 
very common disease, to show that none of us have the 
excuse of lack of material, tor failing to make communi- 
cations here, ('oimiumications which may be instructive, 
stinuilating, of fiir rencliing utility, and incidentally of 
a'real benefit to llie AciuleuiN'. 



Z?rn/c/r /.■.<? on ihv AJhu Trcntmcni uj Diahctc.i. 379 

Forgive me if I appear to have been pedantic, to have 
been lecturing on (hity, and talking platitudes. Intro- 
spection is often a benefit to individuals, to societies or to 
communities; and it tells me that I have been wanting, 
in the directions T have here indicated, and am wishful 
that you will not follow that example. 



Art. XIX. — Reuiarkft on tJw Allen Treatment of Diahetefi.^ 
By Gkoiuj-: E. Kesbitt, M.D., F.R.C.P.T. ; Assistant 
Physician to the Richmond Hospital, Dublin. 

The presentation of this paper, founded as it is on a recent 
and still superficial acquaintance w^ith the subject, is en- 
tirely due to the kind encouragement of the members of 
the Coimcil of this Section, who assured me that even if 
they learned nothing from it, the subsequent discussion 
would probably he profitable. On these terms I venture 
to ask the experience or opinions of others, and to sketcli 
briefly the details of the treatment for those who may not 
yet have had an opportunity of trying it. 

It will be agreed that oiu- treatment of diabetes has 
hitherto left much to be desired both in theory and practice. 
F. M. Allen, of Rockefeller Institute, New York, realising 
our deficiencies, set to work on an elaborate experimental 
research in which he attempted to reproduce, by removal of 
portions of the pancreas in dogs, a condition closely re- 
sembling true diabetes as seen in the human subject. The 
results of this work are given in his book. Studies concern- 
ing Ghjcosuria and Diabetes, published in 1913, and in 
numerous American papers and journals since that date. 
\Yithout entering too deeply into the technical as]iect of 
tlie subject, it may be stated that he succeeded in obtaining 
every grade of apparent diabetes, and it was from the 
behaviour of these animals under various experimental 

* Read before the Section of Medicine in the Royal Academy 
of Medicine in Ireland, on Friday, November 3, li»16. [For the diacus.-ion 
on this; pr>p<rr. ?oe page 417. | 



380 Bcuiarhs on fJte Allen Treat/in ent of Diabctcfi. 

conditions that his deductions were (h'awn as to the 
right hne of treatment. 

" In the milder types, the measures ordinarily used in 
Iniman diabetes — namely, restriction of carbohydrate or 
protein and brief fasting if necessary — suffice to keep the 
animal sugar-free and in good condition indefinitely. But 
in a more severe type these measures do not suffice, and 
the animal quickly passes into a hopeless condition if more 
radical treatment is delayed. Tn this type the initial fast 
must be measured in weeks rather than in days. The 
subsequent diet must be such as to keep the animal at a 
low level of weight and metabolism. Certain influences 
which increase either weight or metabolism tend to bring 
back glycosuria in these animals as in himian patients. If 
glycosuria persists in any animal the result is a downward 
sequence of lowered tolerance, emaciation, w^eakness, 
cachexia and death, with j^arallel degenerative changes in 
Ihe Islands of Langerhans. If glycosuria is prevented, the 
animals may remain lively and strong though thin ; they 
may improve somewhat with tiirie and the islands seem 
to be spared. This evidence supports the hypothesis that 
one set of influences overtax and injure the internal func- 
tion of the pancreas and the o]~ij)osite set of influences pro- 
tect and rest the internal function of the jiancreas." (Trans. 
Assoc. Amer. Phys., 1915. P. 3'23.) 

This extract really sums up the rationale of Allen's 
treatment, which may be divided into three stages — (I) 
l^rolonged fasting; ("2) estimate of the patient's tolerance 
for the various classes of foods (the test being the re- 
appearance of glycosuria); and (3) after-care — nnich of 
which can be carried out by the patient who is taught 
the underlying principles — the essential aim always being 
freedom from sugar. 

The main ])oints of these three stages must be further 
claboraled. (1) Pasting. This is not new, as .Mien points 
out, but the method of a])plica1i()n is. Por a couple of 
(lays after admission the patient reinains on his usual 



By Di{. George E. Nesbitt. 381 

diet, diirinj; which time complete examination of the urine, 
&c., is made. On the third day the patient is put to 
bed at absolute rest, given absolutely nothing except 3-4 
ozs. of black coffee, clear tea, or meat extract, every '2-3 
hours, and water to taste. Jf acidosis or coma threatens 
I to 1 oz. of whisky is given every ■2-4 hours, or it may be 
given merely to relieve the strain of the fast, which is 
continued till the patient becomes sugar-free ('2-10 days). 

This severe initial fast is the most radical departure 
from accepted custom, and is the most probable deterrent 
from a trial of the method. A very large number of re- 
corded cases shows, however, that with reasonable care 
it is perfectly safe, and by no means so trying to the patient 
as might be imagined. Even, according to Allen, " danger- 
ously weak and emaciated patients have borne the fasting 
with apparent benefit, giving the impression that they 
had been suffering more from intoxication than from lack 
of nutrition."' He says that no contra-indication has been 
met, unless it be the appearance of nausea, vomiting, and 
prostration. One woman died in such an attack, but hai 
previously shown similar attacks. A man who began lo 
vomit was fed, the symptoms passed oft', and when he 
was again starved the glycosuria disappeared. 

If serious symptoms of any kind threaten, which is 
rare, all authorities give food, and resume the fasting on 
the first opportunity. It is generally agreed that the clear- 
ing up of the glycosuria by this method is a very simple 
matter, and in my case it presented no difficulty. 

A very remarkable fact in this connection is that acidosis 
wdll also disappear, except perhaps in the most severe 
type of case (Hamburger). This is, of course, the exact 
opposite to- the behaviour of the normal subject, who de- 
velops acidosis on fasting. 

In the severest type of case some modification of the 
above plan will probably be necessary. Joslin"s practice 
in these cases is first to reduce the fats at the rate of 
25 grms. [)er day, during wdiich time the jiatient should get 
no bicarbonate of sodium (NaHCOs), or, if he is getting it, 



382 Remarks on Uie Allen Trcutincnt of Diabetes. 

it should be reduced 10 per cent, daily. The other salts 
should not be omitted. He considers that by the time fat 
is eliminated, acidosis will probably have disappeared. 
Protein is then got rid of in three days, and carbohydrate 
somewhat more slowly. One day's fast will then probably 
suffice to render the patient sugar-free. 

{'!). The second stage of graduated feeding is the most 
troublesome, but also the most important. Its object is 
to ascertain the patient's tolerance, not only for carbo- 
hydrate but for protein and fat. The precise details vary 
slightly according to difl'erent authors, but the process 
is well summarised by Joslin of Boston, who has a very 
large experience of the treatment as follows : — 

Carboliydrath : When '24 hours' urine is sugar-free, add 
150 grms. of 5 per cent, vegetable, and add 5 grms. car- 
bohydrate daily up to 20 grms., then 5 grms. every other 
day, passing through vegetables, fruits, potatoes and oat- 
meal to bread, unless sugar appears or tolerance reaches 
3 grms. carbohydrate per kilogram body weight (1 kilo = 
22 lbs.) (10 St. -64 kilo.). 

Protein : Urine sugar-free two days, add 20 grm. protein 
(eggs), and then 15 grm. daily as meat up to 1 grm. per 
kilo. 

Fat: Not given till protein reaches 1 grm. per kilo., 
then add 25 grm. daily till patient ceases to lose weight, or 
receives not over 40 C. per kilo, {i.e., 2,500 C. for a person 
of lOst. weight). 

On tliese linos salislacloiy [)rogress will be uiado up to 
;i point at wliifh sugar re-appears. Tlie real crux is, liow 
to proceed then. The directions are, however, cpiite ex- 
])licit — fast for 24 hours, or until sugar-free. The diet pre- 
ceding the re-appearance of sugar is I'esunied exce[)t thai 
carbohydrate should not exceed half the Foi'nici' tolerance 
till the urine has been sugar-free for two weeks. In all cases 
a. weekly fast day is recommended, (he severity of the 
fast depending on the carbohydrate tolerance. If under 
20 grms., a com[)lete last; if 20-50, half rations; over 100, 



By Dii. GEoitc.E E. Nesbitt. 383 

half carbohydrate. Most of the cases will probably fall 
into the second group, entailing half diet every seven days. 

Under this regime there is a loss of body weight, and 
Allen lays stress on the fact that this is not only necessary 
but beneficial. He considers that we have made a mistake 
in trying to keep up the nutrition of these patients on the 
ground that increase of weight or metabolism increases 
strain on the pancreatic function. As Cammidge puts it 
in an interesting article in the current number of Tlic 
Practitioner, " one of the aims of the treatment is to 
make the patient a physiological fit for his pancreas." 
This article also gives some very useful tables of food 
values expressed in simple workable fashion. 

(3.) The third stage comprises the education of the 
patient in living up to, or rather down to, his food toler- 
ance. The patients are taught to test their own urines, 
or, if this is impracticable, to have them examined at 
short intervals. It is said that the patients quickly learn 
to check their diet, and in the two years or so which have 
elapsed since the introduction of the method, large numbers 
of patients, under the care of numerous writers, ha v.: 
remained free from sugar. Tn fact a perusal of the litera- 
ture gives one the impression that there are no failures ! 

This brief sketch of the purely practical aspect of the 
treatment scarcely suffices to make clear the points in 
which it differs from previous practice. These are sum- 
marised by Allen in the article already quoted, and may 
be enumerated. (1.) The policy of insisting on prompt 
and lasting freedom from glycosuria and acidosis in nil 
cases ; (2) the thorough nature of the initial fast ; (3) a 
subsequent diet such as to keep glycosuria and acidosis 
permanently absent ; (4) a low level of weight is ad- 
vantageous : and (5) fat feeding may be in itself in- 
jurious. 

Two important considerations will present themselves 
in forming an opinion on the merits of such a revolutionary 
therapeutic scheme ; first, is it practicable to carry out, and 



384 Remarks on the Alhn TnaLiiunt of DiahelfS. 

can we keep the patients sugar-free'? And secondly, is the 
patient better when free from sugar. 1 regret that my own 
experience is so Httle as to be ahnost valueless — indeed 1 
feel considerable reluctance on that ground in bringing 
the matter forward. 

From the testimony of numerous competent and ap- 
[)arently critical workers, as well as from the experience 
of the case just shown, it appears tiuite feasible to render 
the large majority of cases sugar-free. For, at any rate, 
two years they have been kept free, and lapse of time alone 
will tell how long they can remain free. 

The second query is not so easily answered. The patient 
in the sugar-free state is undoubtedly on a somewhat lower 
I)lane as regards liodily activity, and complains of being 
easily tired. Hamburger quotes the case of a physician of 
60, who, when sugar-free, loses weight, looks badly, and 
complains of exliaustion. When allowed a generous diet 
he feels in every way better. The freedom from danger 
of complications should, however, be of considerable 
weight in deciding to endeavour to become sugar-free. 
Joslin says : " If you follow this plan of treatment there 
is little doubt but that you will live longer, only you 
must live at a reduced rate."" This problem is of classical 
antiquity, and is not confined to diabetes. 

The services of an intelligent and conscientious nurse 
are essential, as the patient's future will be founded mainly 
on the ascertained food tolerance. The [)atient"s co-opera- 
lion nuist also be reliable — surre})titious snacks will com- 
pletely upset the accuracy of the test. In both these 
respects I was fortimate. 

Two queries, recently put lo me, uiay be touchetl upon. 
\\ otild this treatment be adx isabic in siu'gical cases before 
o|)eialion? Thei'e is little doubt thai the safety of the 
o|)cratioii would be increased by freedom I'l'om sugar and 
acidosis, and as Ihis condition can be attained it would 
seem very desii'aldc. Tin- point ;il)ont which tolerance is 
readied would seem a very good lime, but the upset and 



By l)ii. (iEORGE E. Nksuitt. ■ 385 

apprehension of tlie operation might be expected to cause 
a return of sugar in a ]m)portion of tlie cases. 

Tile other query concerns tlie question of pregnancy. 
Joslni says that "owing to the apparently easy control 
of diabetes, several diabetic married women have seen no 
reason why they sliould not l)ecome pregnant. So far 
(May, 1915). 1 have treated but one case under the new 
regime, and tliat patient did weH. How other ])atients will 
do I cannot predict." 

Tlie treatment does not pretend to be the hist word with 
regard to diabetes. In reading tlie accounts of those best 
qualified to discuss it, e.g., Allen and Joslin, one is I 
think, impressed by the fact that tliey make no extravagant 
claims. They admit that the success or otherwise of the 
method depends on a yet unascertained factor, namely, 
" whether diabetes is an inherently progressive disease, or 
wdiether it is the simple weakness of a metabolic function." 
Tf the former, this line of treatment would be obviously 
useless, and the patients would go to the bad and die, 
though not of coma. " If the latter, downward progress 
may be indetinitely prevented." They have not so far 
observed this downward ^jrogress. 

Allen concludes one of his papers as follows :— " What- 
ever the ultimate outcome two conclusions seem justified 
by present knowledge : (1) that this treatment removes 
glycosuria and acidosis more quickly and surelv than has 
been the practice heretofore; and {-2) that patients do 
better when glycosuria and acidosis are removed than 
when they are allowed to continue." 

These are the real issues about wliich difference of 
opinion is likely to arise. 

REFERENCES. 
1. Alli'ii. Trans. As.soc. Anier. Physicians. 191a. 
•2. Allen. -Tour. Amer. Med. Assoc. 1914. 1915. 191(5. 

3. Joslin. Trans. As^oc. Amer. Physicians. 1915. 

4. Hambnrgcr. Medical Clinics of Chicago. 191C.. (Vol. I.. No. 0). 

5. Caminidge. Practitioner. Nov., 1916. 
fi. Levton. Ibid. 



386 ■ Drumcondra Iluspital: A Sliurt History. 

Art XX. — Druincondra Hospital: A Short History. 
By E. MacDowel Cosgrave, M.D. Univ. Dubl. : 
Physician in Ordinary to H. E. the Lord Lieutenant; 
Fellow and ex-President of the Royal College of 
Physicians of Ireland, Physician to the Hospital. 



DHUMCONDRA HOSPITAL. 

Opened in 1818 as 
Whitworth Fever Hospital. 

Re-opened in 1853 as 
Whitworth General Hospital. 
Re-named in 1893 
Drumcondra Hospital. 



The above sunniiarised history hangs in the hospital 
hall. In this paper an el'fort is made to add some flesh to 
the dry bones. 

The early history of the Drumcondra Hospital is 
closely concerned with the formation and development 
of the Parish of St. George. 

In 1793 the new district growing up to the north and 
north-east of the Rotunda Hospital was constituted a 
parish, and a plot of ground on the north bank of the 
Royal Canal was given by Lord Mountjoy as a site for 
parish church and graveyard. 

Later on Lord Movmtjoy gave a new site closer to the 
city, and on it the present fine Renaissance church, de- 
signed by Francis Johnston, was opened in 1814. The 
graveyard, however, was opened on part of the canal 
site. 

At the time of the formation of the new parish a 
dispensary in Cole's Lane served the poor of the parishes 
of St. Mary, St. Thoinas. and St. (icoigc, but (his proving 
iiiadequale for the increasing po[)ulalion, some parish- 
ioners, including several medical men. opened, in January, 
]801, a parish dispensary in Dorset Street, adding the 



By Dr. E. MacDowel C'osuiiAVE. 387 

ful lowing year a fever hospital close by on the North 
Circular Koad. 

This was the first fever liospital in Dublin, that in 
Cork Street not being opened until 1884. 

St. George's Place on the Circular Eoad and l)is[)en- 
sary Lane (now' Dorset Place) mark the sites of the two 
buildings. 

Amongst the first attendants were Abraham Codes, 
William Dease, Dr. Plnnkett, Richard Carmichael, and 
Eobert Moore Piel. 

In the Directory for 1818 (the year in which the present 
hospital was opened) the older foundation was named " St. 
George's Dispensary and House of Recovery, St. George's 
Place, Circular Road, North," the attending physician 
being Sir Arthur Clarke (brother-in-law to Lady Morgan). 

Later on, this institution lost its parochial character 
and appears, for the last time, in the Directory for 1859 
as " Maison de Sante of Dublin, George's Place, North 
Circular Eoad. Established A.D. 1816, for the reception 
and treatment of persons afflicted with fever or other 
acute diseases. Superintendent : Hans Irvine, M.B.^ 
1 Rutland Square." 

The late Eobert ^^'hyte, parish beadle until the Dis- 
establishment of the Irish Church, related how Dr. 
Irvine rode down to the Maison de Sante, dismounted, 
tied up the reins, and allowed his pet horse to trot back 
to his stable in Eutland Square. 

In the meantime (1827) a new parochial dispensary 
was opened ; this continued until the Poor Law Dis|)en- 
saries were fully organised, and the need for parochial 
dispensaries disappeared. 

As the fever hospital on the North Circular Eoad was 
unable to meet the demands made ujjon it, having only 
seventeen beds, and relieving annually an average of but 
183 cases, a larger hospital was built in 1816-18 on the 
site originally intended for the parish church. Its origin 
is thus described in Wright's "Historical Guide to 
Ancient and Modern Dublin " : — 



388 Druiiicondra Hospital: A Sliurt History. 

Tlie great distance of the northern extremity of town 
from the Fever Hospital in Cork Street, induced several 
individuals to estabhsh one for the north-eastern part of 
the city, accordingly, about 1816, they determined to com- 
mence a building for that purpose, which they opened 
the 1st May, 1818, under the title of the Whiticorth 
Fever Hospital. It is situated at the third lock of the 
Royal Canal, near Drumcondra, outside the city, and is 
a plain building of brick, with an entablature of granite 
on which are tlie name and date. 

"The construction is somewliat extraordinary; in tlie 
floor of each storey is laid down a large tube opening to 
the external air, and communicating with the interior of 
the ward by valves in the floor ; a corresponding valve 
in the ceiling serves to establish a current of air, so that 
there is at all times a sufficient ventilation. The house 
is so contrived as to be easily capable of extension, but it 
is to be lamented that the present state of the funds does 
not render the completion of the design probable ; it can 
at present accommodate about thirty-five patients with 
tolerable ease." 

The ventilators alluded to are still preserved and show 
how modest were the sanitary ideals of a century ago. 

Shortly after 18-20, Dr. John Barrett, S.F.T.C.D., 
better known as " Jacky " Barrett, becpieathed .£'800 to 
flic new hos})ital, and 4;()00 of this was expended in jnu- 
chasing the freehold of the site. 

Of the early history of the hospital liflle record remains 
except scattei'ed notices in directories and guide books. 
However, for the pasf seventy years im|)ortant hapi)en- 
iugs can be fi'accd Ihicjugh an unbroken series of minute 
Ixjoks. 

'J'hc hi'st entry in these minute books is dated ^rd 
•lannai'y, I''^l"2, and in the earlier volumes the reader can 
trace why and when ihc changi' from a i'cwv hospital to 
a gene»"al hospital look place. 

Fever had hccn lor sonic time less prevalent, aiul in 
1812, " genei'al medical cojnplaijits, particularly fevers," 
were admitted. 



By Dr. E. MacDowrl Cos(ikavk. 380 

The old connection with the parish of St. George was 
still strong, the ]5arochial clergy took a leading part in 
committee work, and meetings were generally held in 
the old vesti-y room now merged in the chancel of the 
parish church. 

Charity sermons usually preached in St. Oeorge's were 
an im])orlant source of income until the Duhhn Hospital 
Fimd was established. Some years several collections were 
given in neighbouring churches, but the Committee was 
not always fortunate; for instance, in 1K()1 ap|)licati()n 
was made to eleven rectors of parishes for sermons, " but 
the Conmiittee received replies unfavourable for the 
reasons stated in their res])ective replies." 

Although the entire cost of running the hosj^ital in 
]84'2 was only £"26'2, the institution was generally in 
debt, and for many years entries of " stock sold " appear. 
In 1848 things came to a crisis ; a special report showed 
that the whole resources of the hospital for the years 
1844-48, inclusive, amounted to :£l,-258, of which £687 
came from the sale of vested funds, the balance of £571 
being the entire of the true revenue for five years, the 
annual expenses averaging £280. 

An interesting report from Drs. Minchin and Seymour 
was received in September, 1848; it gives the weekly cost 
of patients as .5s., and taking twenty as the average under 
treatment makes the following estimate : — 

" Annual expenses will be 
Add Matron's Salary 
Add Nurse. Wardmaid, and Cook, 

each £fi j^er anmmi, and 2s. fid. 

per week 
Add Porter £5 per annum, 2s. fid. 

per week ... 

£329 
The diet of the inmates, coals, candles, soaps, 



£ 


s. 


d. 


2fiO 








20 








37 


10 





n 


10 






390 Drumcondra Ilospita] : .1 Sliort Hif^tory. 

medicines and other necessary expenses will of course 
add considerably to the above sum." 

Having considered this report the Committee resolved 
that all outstanding debts should be called for, all stock 
sold out, and "that it be notified to the inmates that 
their services will not be required after the 1st October, 
1848." 

That this was not the only Dublin hospital in difficul- 
ties at the time is shown by a communication received in 
Novemlier, 1848, from the Committee of the Adelaide 
Hospital asking whether both institutions could' not be 
amalgamated. Dr. Minchin and Surgeon Seymour were 
deputed to find out " whether, if the two institutions 
were amalgamated, patients of all deiiominations might 
not be received." 

No further mention of this project appears on the 

minutes; but in May, 1856, it was reported that £1,300 

was standing to credit of Trustees of the late Adelaide 

•Hospital, and application was made to have it transferred 

to the Whitworth Hospital. 

The threatened outbreak of cholera in 1848 postponed 
the closure of the hospital. On September 11th the 
Committee received a letter from the Secretary to the 
Lord Lieutenant asking whether they could, if required, 
take in cholera patients. An offer to the Board of Health 
of two wards containing eighteen beds was "passed 
unanimously, with the exception of Dr. Tweedy, who 
protested against it." 

In the following year the Board of Guardians of the 
North Dublin Union was in treaty for the hospital, but 
these U(>g()tiations broke off, and the Guardians erected 
cholera sheds higher up on the \\'hit\\()i'th Ivoad. 

As a consecpience the hospital was empty during 1849- 
50, llic matron being retained in charge, the Connnittee 
])aying her wages and expenses. 

The modern history of the h()S])ital dates from 1850, 
as at the end of that year n movement to re-open the 
hospital was set on fool. On Novcnihcr 3()th Surgeon 



By Dr. E. MacDowel Cos(;rave. 391 

William Elliott was added to the Committee, shortly 
afterwards being appointed surgeon. At the same time 
Robert Adams was elected consulting surgeon. In De- 
cember a report was laid before the Committee by Dr. 
Minchin and Surgeon Elliott recommending that the 
hospital be re-opened for medical and surgical cases, and 
that until this be generally known only extern patients 
be treated. 

They also recommended that when the wards were 
opened all cases of urgency (including fevers) should be 
admitted, and that in addition to free cases there should 
also be accommodation " for such as may consent to pay 
a moderate sum of money towards the funds of the insti- 
tution, which will thus render the hospital to a certain 
degree a self-supporting establishment." 

Only two meetings of the Committee are recorded in 
1851, and none in 1852, but in February, 1853, there was 
a meeting at which it was resolved — " that the building be 
used as a Surgical and Medical Hospital, nnder the charge 
of Drs. Elliott and Minchin, but that no cases of fever 
or other contagious diseases be admitted." 

The Dublin Directory for 1854 describes the institution 
thus : " This hospital is open for the reception of j^atients 
labouring under general medical and surgical complaints, 
including club-foot, wry-neck and other deformities." As 
Surgeon Elliott specialised in orthopfpdic surgery his in- 
fluence is shown in the above. These special affections 
are omitted in the 1858 and subsequent Directories, but 
up to the time of Surgeon Elliott's death in 1891 a long 
series of orthopaedic cases passed through the wards. 

Either the hospital was again closed, or the conditions 
were greatly changed, as a resolution was passed on 
January ^Gth, 1856 : — " That the hospital be re-opened 
on the •28th January for two classes of patients, viz., free 
patients, and pay patients, at the weekly sum of two 
shillings." This re-opening was advertised in Sainulrrn' 
Newsletter. 

Both classes of ])atients had at first to supjily their 



39'2 Dm mean (ha Hj)spifaJ : A Slmrt Hisiorij. 

own food, but in the early months of 1856 the Committee 
])rovi(ied food for the free patients. This, however, was 
a short-lived experiment, as in June the admission of 
free patients was suspended — " those in tlie hosi)ital to 
support themselves." 

In 1856 a Ladies' Committee was appointed, and in the 
following year they raised a fund to provide food for 
necessitous patients. Unfortunately this Committee cut 
short their useful career hy resigning in a body in 1858, 
" as they had found that the hospital was not exclusively 
Protestant." The Committee accepted the resignation, 
and regretted that the Ladies' Committee should have 
laboured " under this mistaken impression." 

In order to make the position clear the Committee 
shortly afterwards passed the following resolution : — 
"That it is the fundamental principle of this hospital 
that it shall be open to patients of all religious denomina- 
tions, and that every patient shall be entitled to have 
the attendance and assistance of the minister of his 
religion, when he shall require it, and notify the recjuest 
to the Matron." 

In 1859 Robert Whyte, Beadle of St. George's Parish, 
was appointed Registrar in ])lace of Thomas Hutchinson, 
deceased, who had becjueathed -t'750 to the hospital. 

In the same year a su])ply of water was secured from 
the Royal Canal at a charge of M'2 a year. When the 
North Wall branch of the M.CJ.W. Railway was being 
built the |)i|)e was carried under the new line. During 
the construction of the line the M.G.W.R. made appli- 
cation for the year's rent. The Committee, however, 
pointed out to the Directors " that nineteen of their 
servants had been in hospital during the year, many of 
them suflering from severe accidents, and a large number 
were attended externally." The result was a donation 
of five guineas. 

For some years bazaars in aid of the liospital funds 
were held in tli(> Rotunda. In 1868 special tlianks were 
voted to James Simington " for I'xbibiting dissolving 



By Dr. K. AFacDowf-l CosnTJAVE. 393 

views showing the woiidoiful jiower of the oxy-calcium 
lio-ht." 

Up to this time the drainage and suiToundings of the 
liospilal were insanitary. The water from tlie workhouse 
sheds flowed through an open ditch in front of the grounds. 
and the hospital drains emptied into a cess-pit at I he side, 
Tn 1863 tlie ditch was piped and covered, hut the cess-pit 
remained until 189'2, although when a sewer was con- 
structed down the Whitworth Road an overflow pipe had 
been carried to it. 

For some years active work languished, and the hospital 
threatened to become a refuge for chronic cases. Tn 1870 
the Committee called the attention of the medical men 
to the fact that one patient liad been in the hospital for 
over four years, and two others over a year. This did not 
cure the evil, for in 1874 the Committee passed a re- 
solution that no patient should remain in the hospital for 
more than a year without their special permission. 

In 1877 the Ladies' Committee became still more active 
and passed a resolution that they thought " it would be 
a most advisable thing if the Gentlemen could make it 
convenient to hold their Committee Meetings occasionally 
at the hospital, and then inspect the house." 

In the same year the return building was erected at 
a cost of £285 from the designs of F. V. Clarendon, a 
member of the Committee. 

In 1878 the " Croasdale Bed" for cases of heart dis- 
ease and the "Kennedy Bed" were endowed. 

In 1881, for the second time in the long liistory of the 
hospital, there was a surplus, and it is recorded that " in 
consequence .... of the ample funds now at the dis- 
posal of the Committee two additional free beds were 
opened." 

In 1884 a new roof was built, and Vartry water was 
introduced for drinking purposes. 

Miss Marion Simj^son was appointed Matron in this 
year; she was the first trained nurse to hold tlie position. 

Tn 1885 tlie " Haughton Bed" was endowed. 

2 F 



394 Drvnico}i(]rn Hospital: A SJiorf hiiftfory. 

In the report for 1885 the division of beds into 
absohitely free and those for which a small weekly sum 
was paid is alluded to as a recent arrangement. This 
arrangement, which still obtains, had however been tried 
at an earlier period. 

The decade of the ' ' Eighties ' ' was a stormy period in 
the history of the hospital. The programme of the party 
of progress — at first a small minority of the Committee — 
was : (1) the hospital to be used for the sick, and not as a 
cheap refuge for the old and infirm ; (-2) A Medical Board 
to be established ; (3) Medical men to have seats on the 
Committee ; (4) An annual meeting of subscribers to be 
held for the election of Committee and Officers. Truly, 
a modest platform, yet it was bitterly opposed, and in 1884 
when the present Bishop of Killaloe proposed that an 
annual meeting should be held he failed to secure a 
seconder ! 

However, year by year as the personnel of the Committee 
changed, the minority rose to be the majority, and two 
short paragraphs in the annual reports of 1889 and 1890 
record the end of the struggle : — 

" Having given much consideration to the question 
the Committee decided to request the medical officers to 
constitute themselves a Medical Board as in other hos- 
pitals, with a view to their consulting together and 
expressing their opinions on the subjects which may be 
referred to them for consideration." 

"After serious consideration the Committee thought 
tliat the presence of the visiting medical officers at the 
meetings would conduce to the more efficient working of 
the hospital ; (hey have accordingly elected them mem- 
bers of the Committee." 

Fr(jni this time onwaids the history of the hosjntal is one 
of impi(jvement and incicased iisefnhu^ss, and ahhough the 
Committee have, had anxieties they have had generous 
support, and every im))rovem('nt planiu'd has been suc- 
cessfully carried out. Some of the geneioiis b(MU'factions 
and ini|)rovements may be mentioned. 



By Dr. E. :\r\cDo\YRL C'ororave. 395 

In 1889 Mrs. Caledon Dolling' oroanised a concert from 
which the hospital received £10. 

In 1892 Mrs. Neilson Hancock, Hon. Sec, Ladies' 
Committee, paid for a new system of drainage carried out 
from the designs of Kaye Parry. 

In 1893 the name of the hospital was changed from 
" Whitworth " to " Drmncondra." In doing this the 
Committee had a douhle motive — the old name being 
similar to that of another hospital. Letters, and even 
patients sometimes, went astray, and the fields which 
surrounded the isolated fever hospital having been covered 
with liouses, and converted into an attractive suburb, it 
was hoped that the territorial name would excite local 
interest and support. 

This year a Ball held in the Rotunda realised ^£60. It 
was the first of a series of sixteen annual balls organised 
by Mrs. MacDow^l Cosgrave and a committee of ladies, 
assisted by some members of the statT and outside friends. 

In 1894 the Ladies' Committee refurnished some of the 
wards with modern beds and bedding". 

In 1895 an Oculist and a Gynaecologist were added to 
the staff. 

In 1896 a bed was endowed in memory of Dr. H. N. 
Eustace. Two memorial grates were inserted. The side 
tiles were painted in Cooper's studio, and they bear the 
inscription : — 

" In memory of Rachel A. Blood. Ob. 15 April, 
1895. Erected by the Dublin Club of Living Chess. 
' She hath done what she could.' " 

This year a fancy dress ball, organised bv Mrs. 
Graham, brought in £182. 

In 1898 Miss Creighton-Williams, with the cordial as- 
sistance of her pupils in the Rathmines Ladies' College, 
arranged an entertainment in aid of the funds. This 
kindly act has been repeated yearly ever since. 

New tables and benches, specially designed by T. R. 
Scott Si Co.. were placed in the wards, and Mrs. MacDowel 



396 Druuicovdra Hofipital : A Short History. 

Cosgrave gave a complete supply of case sheet and chart 
holders. 

Ill 1899 a sum of £1,500 having been received from the 
executors of the late James Weir, important structural 
improvements were carried out from the ]:)lans of Mr. C. F. 
Ashworth. The annex was lengthened ajid raised two 
stories, a well equipped and lighted operation theatre, a 
private ward and excellent bathrooms and lavatories were 
built. 

A brass plate over the theatre door records this 

generous bequest : — 

"The James Weir Operation Theatre, 1900." 

In 1901 Miss Black left a legacy of £1,000 to be in- 
vested, and the interest applied to the support of free 
beds. 

In 1902 Dr. Cosgrave erected a new entrance to the 
Dispensary. 

In 1903 Lord Iveagh gave £300, which was used for 
pressing repairs and improvements. 

In 1904 Miss Creighton-Williams and her pupils gave 
two entertainments, and with part of the money erected 
an open-air shelter in the grounds. William Butler, a 
member of Committee, supplied the design. Tiles painted 
in Cooper's studio bear the inscription : — 

" The MacDowel Cosgrave Pavilion. 

Presented to the Drumcondra Hos))ital 

By the Rathmines Ladies' 

Collegiate School, 

1904." 

In 19()(; Miss Creighton-Williams and bor |)upils gave 
over I'll lo the bos|)ilal. Tbc Connnittce, as a mark of 
gratitude for \\\v fi'cciiiont help received, dodicaied a cot 
to the school, and placiMl over it an oak slab willi ilic 
words : — 

" Tlic ( 'rcigliton-Wiliiaiiis and IJallnnincs Ijadics" 
College Cot, 1907." 



By Dii. Iv MacDowel Cosgkave. 307 

This year Miss Bolton and the pupils of Kenniare 
College organised a sale of work, and handed in £-55. 

For some years special eflorts were made to raise a sufli- 
ciently large sum of money to further improve the hospital 
and render its financial jjosition secure. 

In 1907 the "Drum Fete " was held in the hospital 
grounds, and was a great success, £567 jirofit resulting. 

In 1908 a second "Drum Fete" on a smaller scale 
brought in £141. This year the grounds were planted 
with choice trees and shrubs from the Exhibition grounds, 
Ball's Bridge, and ever since Messrs. Hogg & Robertson 
have kept the beds well supplied with bulbs. 

Up to this, owing to the gradual development from a 
fever to a general hospital, the system of government was 
not clearly defined. This year the fault was corrected, and 
a carefully drafted constitution and rules were adopted, 
which have since worked well. Judge Orr and Mr. Andrew 
Dawson were elected first Chairman and Vice-Chairman, 
and still retain the offices. 

In 1909 a concert given in the Rotunda brought in £90. 

In 1911 the special efforts culminated in tlie " Big Drum 
Bazaar," which was held in the Rotunda. The profits were 
£1,110, including £106 made at a matinee organised by 
Miss MacNie in the Gaiety Theatre. 

This year Lord Iveagh seni £200 as portion of the 
" King's Gift." 

In 1912 two new posts were created. Consultant in 
Mental and Nervous Diseases, and Pathologist ; and the 
Linen Guild was started by Mrs. Stephenson. 

In 1913 a generous gift was received, it is recorded on a 
tablet in the hall : — 

" In Memory of 

Gertrude 

Countess of Pembroke. 

A sum of £300 was granted out of 

The Pembroke Irish Charities' Fund 

Towards Improvements in this Hospital. 

A.D. 1913." 



398 Drunicoitdni Hosijital : A Short History. 

In 1914, on the breaking out of war, a ward containing 
ten beds was set apart for wounded soldiers. 

In 1915 a pavilion for open-air treatment was erected 
in the grounds, a commemorative tablet explains its in- 
ception : — 

" The Blandford Memorial, 

Presented by the Co-operative Congress 

Assembled at Dublin, 1914, 

In memory of 

Thomas Blandford, 

Who was a Fellow-worker in the Movement." 

As a result of all the special efforts and gifts recorded 
above, the Committee have been enabled to modernise the 
hospital buildings, and make important alterations and 
additions. Amongst these may be mentioned an annex 
with accommodation for the Lady Superintendent and the 
Resident Medical Officer, bedrooms for nurses, staff' bath- 
rooms, a large storeroom and larder, new windows through- 
out the hospital, electric lighting and heating installations, 
remodelling operation theatre and laying terrazzo floor, 
service lift, lead treads and linoleum on stairs, and 
thorough renovation of beds, bedding, and ward fiu'niture. 
During the same period the grounds were further improved 
and were enclosed by substantial walls. 

ROLL OF MEDICAL MEN ATTACHED TO THE 
HOSPITAL. 

Physicians. 

Dr. James F. Leahy ... ... 1818-18-J8. 

,, William Stack " ... ... 1818-18-Ji2. 

W. J. Morgan ... ... 1818-1834. 

Peter Edward McLoiighIm ... 1818-1819. 

Kamage ... ... ... 1819-18-J-J. 

11. J. (Graves ... ... 1821-18'23. 

Tlioi.iiis Lee ... ... 18-2'2-18'23. 

John .Mollan ... ... 1831-1848. 

IIiim[)lirey Almclnn ... 1848-1854. 

John Seymour ... ... 1848-1850. 



By Dn. E. MacDowi^l CosgHave. 



399 



Dr. George Johnston 


. 1854-18G«. 


,, John Mallet Purser ... 


. 1808-1809. 


,, Guinness Beatty 


. 1869-1876. 


, , Henry Kennedy 


. 1876-1887. 


,, MacDowel Cosgrave 


. 188-2- 


,, Ninian M. Falkiner 


. 1887-1889. 


,. Arthur K. F. McCutcheon 


. 1889-1901. 


,, G. O'Keefe Wilson ... 


. 1899- 


,, Edward M. Fannin ... 


. 1906- 


Consulting Physicians. 


Dr. John Cheyne 


. 1823-1884. 


,, James Pope 


. 1834-1837. 


,, W. C. Beatty 


. 1837-1843. 


,, Richard S. Sargent 


. 1843-1848. 


,, John MoUan 


. 1848-1877. 


,, George Johnston 


. 1868-1889. 


Sir John William Moore 


. 1889- 


Surgeons. 




Mr. Robert Adams 


. 1818-1850. 


,, W. Wright 


. 1818-1823. 


,, William A. Elliott ... 


. 1850-1891. 


,, William H. Elliott ... 


. 1872-1876. 


,, George Maliood Foy 


. 1876- 


,, Graves Stoker 


. 1892-1915. 


,, Seton Pringle 


. 1915- 


,, Albert E. Wynne ... 


. 1915- 


,, Henry Stokes (acting) 


. 1916- 


,, L. G. Gunn (acting) 


. 1916- 


Consulting Surgeons 




Mr. Robert Adams 


1850-1875. 


,, James H. Wharton ... 


1881-1892. 


,, William Stoker 


1892- 



Ophthalmic and x\ural Surgeons. 
Mr. R. J. Montgomery ... ... 1895-1912. 

,, R. H. Mathews ... ... 1912- 



400 Druincnmha Hospital: A Short History. 

Gynaecologists. 

Dr. Robert A. Flynn ... ... 1895- 

C0NSULT.\NT IN MeNT.\L .\ND NeUVOLS DiSE.\SES. 

Dr. Henry M. Eustace ... ... 191-2- ; 

P.4TH0L0GIST. 

Dr. E. M. Bronte ... .. 1912- 

An^sthetists. 

Dr. Edward M. Fannin ... ... 1900-190(1. 

,, Paul Carton ... .. 1903-1915. 

,. Albert Wynne ... .. 1912-1915. 

.. William F. Delany ... ... 1915- 

Dentist, 

Mr. Henry Sherlock ... ... 1870- 



RICKKTS. 

Dr. Eric Pritch.ard has an interesting article in the October 
number of the British Journal of Children s Diseases, on 
the cause and treatment of rickets. His theory is that if 
the total amount of food exceeds the caloric requirements, 
then, owing to insuificient oxidation of the food, the blood 
is Hooded " with acid bodies of large molecular size " {e.<j., 
oxalic, uric, diacetic acids, &c.). These are neutralised at 
once, but only by calling up large reserves of basic materials, 
such as calciuni, which are, therefore, withheld from mor*' 
iiiipoi-laiit eombinations. 

'rile disturbances set up thereby aie in the nature of an 
acidosis, destroying blood corpuscles, &c., the enlarged 
epiphyses being a form of compensatory activity in the 
hieniatogenetic organs. 

His treatment depends on increasing oxidation by exercise, 
massage, cold douches, &c., and a ri'sti'icted non-carbo- 
Ii\drate diet. Verv irood icsuhs are claimed. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Eclipse or Empire? By Herbert Branstox (tRay, D.D. 
Oxon. ; and Samuel Tlrxer. London : Nesbit & Co., 
Ltd. N.D. Octavo. Pp. x + 316. 

A BOOK of interest and value, and, unlike most books of 
reference, permanent rather than ephemeral, the greater 
part dealing with inventions and manufactures and the 
countries responsible for their origin and improvement. 

The section devoted to the healing art is of special 
interest to medical readers. It is divided into : — A , 
Bacteriology and Pathology; B, Details of investigations 
and new treatments; C, Medicinal substances; D, Ap- 
pliances; E, Proprietory Medicinal Articles. 

In Section A we find that though the foundations of 
bacteriology were laid by Pasteur and Lister, the super- 
structure has been reared largely by German scientists. 

The other sections contain variants of the same story ; 
either Germans led in discovery and manufacture, or, if 
others originated, (jermans step])ed in and made improve- 
ments or manufactured more cheaply, in either case getting 
the trade into their own hands and crushing out their 
rivals. 

In tropical pathology and bacteriology the bulk of dis- 
coveries have been made by British, French, and (to a 
smaller extent) Italian scientists, who have the advantage 
of belonging to the great Colonial Empires. Even here, 
however, we are again handicapped, as necessary glass 
apparatus, dyes, and culture-media are largely of German 
])roduction. 

One reason why Great Britain falls behind is explained 
by the proportionate number of chemists in various 



402 Reviews and BihliugrapJiical Notices. 

European countries, the respective populations being re- 
duced to the same scale — Switzerland, 300; Germany, 
250; France, 7 ; England, G. Tiiis table will explain how 
Switzerland is now supplying us with so many drugs, for 
which, before the war, we depended on Germany. 

The section on Education deserves careful study. The 
authors fully realise the biological principle that the liigher 
the type of the organism the slower is the progress towards 
maturity, and that early precocity may be evidence of a 
lower rather than a higher type. 

This is a book to read and keep, and the low price at 
which it is issued (two shillings net) places it within the 
reach of all. 



Studies in Bloud Pressure. By George Oliver, M.D , 
London, F.H.C.P. Edited by ^A^ D. Halliburton, 
M.D., F.E.S. Third Edition.^ London : H. K. Lewis 
& Co., Ltd. 1916. Demy 8vo. Pp. xxih + -240. 

The regretted death of Dr. Oliver at the end of last year 
prevented his personal completion of the work of this 
edition. The majority of the chapters had, however, been 
re-written— indeed the only portion of the book for which 
Professor Halliburton is responsible is that dealing with 
treatment, which is taken mainly from the previous edition 
and brought up to date with the assistance of Dr. Alfred 
Mantle. 

The present volume is considerably changed in ap- 
pearance from the familiar little book wliich did so much 
to educate us in the study of .Blood Pressure. Its essentials 
are, however, the same, and we know of no better guide 
to at least a preliminary acquaintance with the subject. 

Of Oliver's services to this depai'tment of scientific 
medicine it is hardly necessary (o speak — il was, never- 
theless, a happy inspiration to include^ in lli(> book by way 
of i)reface an article jvpi'oduced from I lie Liineet dealing 
with his achievements and (hcii practical importance. 



Jamieson— T/ic Basic AiuUoinical Noiiicnclaturc. 403 

A Practical Manual of Dandagimj. By Duncan C. 
L. FiTzWiLLiAMS, Captain R.A.M.C.T. ; Suigeon-in- 
Charge of Out-patients to St. Mary's Hospital and to the 
Sick Children's Hospital, Paddington. London : Bail- 
liere, Tindall & Cox. 1915. Demy 8vo. Pp. viii +9-J. 

A BOOK on bandaging cainiot contain niucli new matter. 
The subject necessarily is dealt with in all text-books on 
surgery ; withal it is a convenience to have at hand a 
manual on bandaging ; and tins handbook can be re- 
commended as being well printed in large type, and some 
140 figures in the text. There is a plate illustrating a foot 
sling, which we suggest should be omitted in all future 
editions. 

On page 16 we read : — " Encu'cle the tinger with a 
loose spiral till the tinger-nail is reached ; then begin to 

ascend the finger with an ordinary spiral Wlien 

the web of the finger has been reached, carry the roll 
again round the wrist. If necessary, the other fingers can 
be bandaged in the same way." This is, as Lord Dun- 
dreary used to say, " something no fellow can understand." 
It may, however, be made intelligible in future editions. 



The Basle Anatuniical Noinenclaturc [B. N. A.]. Being 
an Alphabetical List of Terms showing the Old 
Terminology, the B. N. A. Terminology, and the sug- 
gested English Equivalent. By E. B. Jamieson, M.D., 
M.B., Ch.B. (Edin.), Lecturer on Anatomy, University 
of Edinburgh. London & Edinburgh : W. Green & 
Son, Ltd. 1916. Large 8vo. Pp. viii + 91. 

In an introductory explanation, Dr. Jamieson reminds us 
that the list of names comprised in the revised anatomical 
nomenclature was prepared, after six years' work, by an 
International Commission of Anatomists. This list of 
names was submitted to the meeting of the Anatomical 
Society at Basle in 1895, at which it w^as adopted by the 



404 Reviews and Bihiiographical Notices. 

Society — hence the name Basle Nomina Anatomica 
(B.N. A.). 

Dr. Janiieson goes on to state that the chief principles 
underlying the work of the International Commission of 
Anatomists were that each structure in the body should 
have only one name, that the name should be a " sign- 
post " or " memory sign," and that, if possible, the name 
chosen should be the most suitable of the alternative names 
already in use. There are, therefore, very few names in 
the B.N. A. which are altogether new, and the list is a 
revised and lightened nomenclature rather than a new one. 
Latin — that wonderful language which is being dropped 
by some of the modern English imiversities — was the 
language adopted for the nomenclature, as it is common 
to all (civilised) countries. 

The nomenclature proper consists of two parts — Terms 
indicating position and direction, occupying only one page; 
and the Anatomical Names, constituting the remaining 
90 pages of a large octavo volinne. The terms and names 
are arranged in three parallel columns headed respectively, 
"Old Terminology," " B. N. A. Terminology," ahd 
" Suggested English Equivalent." Many of the entries 
in this last column are not English at all, but pure Latin — 
for example, " Aditus ad antrum," " Area cochlete," 
" Areola mammse," and so on. 

The book cannot fail to prove a most useful work of 
reference to all medical writers and readers. 



L'eport oj the Director-General of Public Health, New 
Soulh Wales, for 1914. Sydney : W. A. Gullick. 1916. 
Eoho. Pp. 200. 

This vohime contains a large number of reports and 
ilhistrative tables. Amongst the reports of investigational 
work is ail interesting sumniaiy of researches on plague, 
including a six-year table showing the varieties of fleas 
loinid and their j'ates ])cv 1 ,()()() rats examined. La-nio- 
[)sylla clieoj)is was usually the most numerous, its chief 



RrssRLL— A/ofr,9 on ihc Camnimi of Cancer. 405 

incidence being about March. Ctenopsylla nuisculi 
generally came next, its maximum being about October; 
in 1914, however, it greatly outnumbered L. clieo|)is. 
Pulex irritans was not found on any of the rats examined. 
On the declaration of war much of the investigational 
work was suspended, as the microbiological laboratory had 
to be given up to the preparation of anti-typhoid vaccin(> 
for the troops leaving Australia, the laboratory stafl' 
carrying out most of the inoculations in New South 
Wales. 

That "'quack" medicines are dealt with more wisely 
in Australia than in the mother country, is shown by the 
following extract : — 

" A aood deal of the time of the Analytical Branch is 
devoted to examining specially advertised preparations and 
appliances. Large businesses of a nefarious character 
have grown up in recent years in all the States as a result 
of extensive advertising of pre]uirations and appliances that 
are often harmful, usually (piite worthless, and always 
misleading and dangerous, because in very many cases 
they ])revent sick persons frojn obtaining proper treatment 
in time to save them from prolonged or even fatal illnesses. 
.... The Department is taking vigorous action for the 
suppression of these advertising imposters, who are such 
a menace to the conmiunity, not only from the fact that 
these advertisements are one and all fraudulent — inasmuch 
as they refer to preparations which cannot, and do not, 
cure the ailments for which they are recommended — bul 
also from the fact that ])roper skilful treatment is being 
delayed." 



Notes on the Cnnsation of Cancer. By the Hon. Rollo 
RrssELL. London : Longmans, Green & Co. 1916. 

Much patient and enthusiastic work has been devoted to 
the compilation of this little volume, the ]Md)lication of 
which the author did not, unfortunately, live to see. An 
enormous amount of statistical information has been 



406 Ervinrfi ami Bihlio(irnp]iira] Noticefi. 

collected, the gist of which seems to point to the inflneiice 
of irritating foods and drinks in the causation of cancer. 
The author, however, appears to have first formulated his 
theories, and " in every case the expectation has heen 
verified." 



Studiff! in SiircjicaJ PathoJociical Phyfiiology from the 
Laboratory of Surgical Research. New^ York Univer- 
sity. 1915. Vol. I. 8vo. 

This volume of 631 pages contains 28 papers dealing with 
surgery. The first series deal with the functions and 
diagnosis; the second, with the details of method and 
technique; the third, with studies of the alimentary and 
neural canals; the fourth, the influence of chemistry upon 
surgical diagnosis. Following these are the details of a 
series of studies on the neuro-muscular system. A care- 
ful study has been made on the intricate subject of shock, 
the results of which are very well calculated to overthrow 
many long established opinions on the subject. The 
different I'japers have from time to time appeared in current 
medical literature ; and now in their collected form they 
well repay re-reading and form a useful addition to a 
medical library. 

Dkeases of Children. By A. Dtnowall Fordycr, M.D., 
F.R.C.P.E. ; l^xtra Physician Royal Hosp. for Sick 
Children, Edinburgh. London : A. c^' C. Black, Ltd. 
V.UCk 8vo. Pp. 47r). 

ALTiTOT'dii lext-books on pa'dialrics are inimerous we are 
glad to welcome one from the pen of Dr. Fordyce, as 
there has always been something jiarticularly suggestive 
and purposeful in his writings. The present book, which 
is a compact octavo vohime of 476 pages, seems to aim at 
two things — the lirsl, lo gi\(" ;i syslcuiat ic and chissilied 
accoiMit of the (hscascs of childhood; and the second, to 
(■nipli;isise the ini[)()t|ance of diet as a factor iti health. 



Tlif Inicn^iaic Medical Journal. 407 

He beoins with a couple of useful chapters on the manao-e- 
ment and examination of a sick child, and describes the 
difficulties which usually beset the newly qualified prac- 
titioner when faced with an anxious mother, a crying child. 
and an obscure diagnosis. 

rollowing this there are two chapters on diseases of the 
newly-born, and then seven on diet and diseases of nutri- 
tion. Tn these there is a very clear and good descriptioii 
of the "caloric" method of calculating the amount of 
food, but hardly anything is said about the percentage 
method ; and the classification of nutritional disorders and 
their treatment is rather confused. After this the systemic 
diseases are taken seriatim as in an ordinary text-book 
on Medicine. 

The illustrations are good — notably a series on tlie 
fades of different pathological conditions — but the coloured 
plates representing the motions of infants with nutritional 
disturbances might, with advantage, be more numerous, 
as these are of great value, especially to a young and in- 
experienced physician. 

The book is one which can be confidently recommended 
to students and busy general practitioners. 



The Interstate Medical Journal. Vol. XXIII. No. G. 
June, 1916. 

The one hundred and twenty pages of this number of the 
Interstate Medical Journal are wholly given up to the 
subject of alcohol and narcotics. Both subjects are of 
deep interest ; but it is quite possible to get too much of 
a good thing, as Duke Dunstable in "Patience" tells 
Major Murgatroyd, " Toffee in moderation is a capital 
thing. But to live on toflf'ee — to have it supposed that 
you care for nothing but toffee .... how would you 
like that?" A whole number given over to alcohol, for 
in this case narcotics form a side show, calls for the 
literary thirst of a Teufelsdrockh. The editor has, however, 
served a rather appetising feast, he has secured contri- 



408 Reviews and Dihlioriraphirnl Notices. 

butions from many States, and from well-known writers, 
and if the articles are unequal in value the inequality is 
common to all magazines. It seems unfortunate that 
writers on alcohol as a stimulant, narcotic, therapeutic 
remedy, or table drink, write so intemperately that they, 
as a rule, injure the cause they desire to support, and, not 
infrequently, drive away from the study those who came 
to learn the most recent teaching of the science and ex- 
perience on the subject. 

We well recollect how much was expected of Ariel 
Gustafon's work on the drink question, but the distin- 
guished author ruined its chance of either securing a 
circulation or doing any good as a temperance manual 
or a scientific work by its intemperate title, " The Foun- 
dation of Death." Temperance advocates as they pass 
from town to town meet with select bodies of elderly 
ladies of a decent social position, who listen to the lectures 
and buy the literature; not so nuich to acquire knowledge 
as to have the satisfaction of seeing their own views ex- 
]:)resSed in print. These faultless observers of the conventu- 
alities of life are, as a rule, excellent people in their way. 
As, however, rare Ben Jolinson said, " their souls live up 
an alley." And if they should wander from their doorstep 
they hurriedly scuttle back or die unknown in the rush of 
humanity. The deductions of these intenijierate advo- 
cates are drawn from an absurdly small number of facts ; 
and they close their eyes to the great world around them, 
and to the teaching of history. Time, jiast and present, 
controverts their whimsical theories. We are reminded 
of this ilieir s|)ecial pleading, their pseudo-scientific experi- 
ments, and Iheir oracular pronouncements on reading Dr. 
Charles R. Stockhard's article, "The Hereditary Trans- 
mission of Degeneracy and Deformities by the Descen- 
dants of Alcoholized Mammals." Why, the very title 
tells of prejudice and of a cerebral warp. Of all animals 
the author's choice Coi' e.Kperimentation fell on guinea- 
pigs, mice and agouti, all three belonging to the last 
(l(>vclopc(l cerchral tvpe of rodents. In tlic dosing years 



Maiirltcfiirr Bahicfi' HoftpitaJ. 409 

of the eighteenth century WilHam Higoins demonstrated 
that the ethyl group of the alkyl series primarily and 
pi-incipally affected the cerel)rum, and prophesied that 
from it would come a surgical ana'Sthetic. Dr. Stockhard 
illustrates .his paper hy jiortraits of the descendants of the 
victims of alcoholism, to demonstrate the physical effects 
of alcohol on a very low type of brain. All this is irrelevant. 
He cannot by experimenting on animals in whom the 
cerebrum is hardly existent draw accurate, or even approxi- 
mately accurate deductions of its effects on the most 
highly organised brain. And yet he fills nineteen pages to 
try and convince iiis readers that physical degeneration is 
a normal and unescapable result of heredity'. Russian Vodka 
drinkers have l>red sons who contest bravely against the 
bravest of the Teutonic beer and wine drinkers, as do our 
beer-drinking Englisli and whisky-drinking Celts. All the 
lessons of history are lost on him; he will. Quixotic-like, 
charge windmills to his grievous undoing. The twaddle of 
temperance literature is nauseating. We all desire temper- 
ance, and it is coming, and drunkenness will in due time 
greatly decrease in the land. Steam and electric machinery 
disqualify men from employment ; a fact that is being 
recognised by the working classes and all others. Machinery 
compels men to be sober, and from it they will soon see the 
necessity for sobriety, to the exchision of temperance 
pledges, temperance literature and temperance lectures. 



Mauclicfitfr Bahic.<i' Hospital. Medical Registrar's Report, 
August, 1015, to July. 1016. Manchester : Univ. Press. 
Price Is. 

This pamphlet consists of a series of condensed case sheets 
of the various infants admitted to the hospital during the 
year. To anyone who will peruse it carefully it affords 
useful reading, as the progress under various forms of 
treatment is faitlifuUy recorded. The number of cases 
admitted during the year were 50 males and 44 females. 

2 G 



410 Ucvirv\'; mid P>ihVio(jrnj)h\cn} Notices. 

The Medical Clinics of Chicago. Vol. I. Nos. 5 & 6 
W. B. Saunders Co. 

THElast two numbers or Vol. 1. of these "Clinics" increase 
our already favourable opinion of the series. In .our reviews 
of previous numbers we have indicated the scope of the 
work, and referred in eulogistic terms to the manner in 
which it was carried out. The present numbers show no 
departure from the former high standard— the articles, 
which range over a wide field, are invariably epitomes of 
modern knowledge of the subject, presented in a liiost 
attractive condensed clinical form. 

As usual, we find it difficult to particularise ^ and we 
mention the following articles more vritli the object of 
illustrating the useful character of the book than from 
any desire to institute unfair comparison. 

In No. 5, however, w^e jiarticularly enjoyed the accounts 
of the "Rontgenologic Aspects of Intestinal Stasis," 
" Carcinoma of tbe Stomach simulating Pernicious 
Ana'mia," "Banti's Disease," and "Congenital Syphilis." 

No 6 forms a fitting climax to the series, and is replete 
with information concerning a wide variety of subjects 
from the Ahen treatment of diabetes to mycosis fungoides 
and rickets. This number also contains an admirable 
index to the series — a feature which adds enormously to 
the value of the work for ])ur])oses of reference, and gives 
some impression of the surprising extent of groimd covered 
in the six numbers which comprise Vol. T. 

We have nothing but |)raise for this undertaking, and 
can cordially recomuuMid it to those who wish to keep 
abreast of the most ii'cciil chm'cal toacliing. We look 
forward with the koenosi ;in1icipn1ion to further volumes 
of the same sciics, 



PART III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scientific Intelligence. 



BIOLOGICAL SOCIETY OF THE EOYAL COLLEGE 
OF SURGEONS IN IRELAND. 

Captain T. Gillmax ]\Ioorhead, R.A.M.C, Professor of 
Medicine, delivered the inaugural address at the annual 
meeting of the Biological Society of the Royal College of 
Surgeons in Ireland in the Examination Hall of the College, 
on Wednesday evening, November 1,1916. His subject was: 
" Some Experiences in a Base Hospital in Egypt." 

The chair was occupied by Lieutenant-Colonel William 
Taylor, President, who was accompanied on the platform 
by the Lord Lieutenant, his Grace the Most Reverend John 
Henry Bernard, D.D., D.C.L., Lord Archbishop of Dublin, 
Surgeon-General Ford, Mr. H. Hurst (Vice-President of the 
Society and of the Students' Union), and Mr. J. C. M. iNIartiu, 
(Hon. Sec). 

The President expressed the sympathy of the meeting 
with Sir Robert Woods, a Past President of tlie College, and 
Lady Woods, on the death of their son, Lieutenant Woods, 
who had been killed in action. There was no way in which 
a man could die a nobler death than in fighting for his coun- 
ti-y, and if anything could console Sir Robert and Lady 
Woods it was that their son had died doing his duty, and 
that they would have the sympathy of everyone, from his 
Majesty to the lowest in the land. It was his (the Presi- 
dent's) pleasing duty to welcome his Excellency on behalf of 
the Students' Biological Association of the College to its 
annual meeting. It was not by any means the first time 
the Representative of His Majesty had visited their hall, but 
it was certainly the first time the Representative of His 
Majesty had visited the annual meeting of the students of 
the Biological Societv of the College, and on their behalf 



412 Biological Society of the B.C. S.I. 

he begged to return the most sincere and respectful thauKs 
for the honour the Lord Lieutenant had done them. 

Professor Moorhead thanked the members for asking 
him to dehver the Inaugural Address. The war still 
occupied all minds, and as he had recentl_y spent a 
period of nearly a year in medical work in Egypt he 
felt that some description of that work would not be 
out of place. From the very commencement of the war 
the hospital to which he was attached, in common with 
all the Dublin hospitals, threw open its wards to wounded 
soldiers, and in this way familiarised the staff with military 
work. When the report came that there was much medical 
illness in the army in Gallipoli he personally felt that he 
would like to have a more direct share in the work. He 
reached Alexandria on the 31st of last December. To one 
unaccustomed to military forms the first contact with the 
organisation of the R.A.M.C. was rather bewildering. Un- 
familiar collections of letters designating officers with still 
less familiar duties become mingled in one's mind in, at first, 
inextricable confusion. It was surprising, however, how 
rapidly one began oneself to think in military shorthand 
and to realise that names and forms at first perplexing were 
useful and part of a dovetailed system. During the next 
few weeks he gradually acquired a knowledge of the general 
medical establishment in Egypt. Base hospitals predomi- 
nated owing to the fact that Egypt had become the primary 
medical base for Gallipoli. In Alexandria there were four 
large hospitals for European troops, tw^o for Indian troops, 
and the local Egyptian Government Hospital. Of the four 
general hospitals his own was the largest, being capable of 
accommodating 2,500 patients and staffed by 40 medical 
officers. The Colonel in Command, Colonel Healy, was a 
Dubliner, while the Matron, also Irish, had been trained as 
a nurse at St. Vincent's. All visitors to France were much 
struck l)y the organisation of the medical forces there, and 
lie thought a similar high quality characterised the arrange- 
ments in Egypt. Of the three hospital buildings one was 
allocated entirely to surgical work, one to enteric cases, and 
one to general medical cases, but only a comparatively small 
number of the i)atients were treated within the l)uildings, 
the remainder being dealt with in wooden huts and in tents, 
which, as far as ])ossible, were grouped into special area-j 



Biological Society of the ll.C.S.l. 413 

according to tlie ty])e of ease they were to receive. Tiie 
medical officers all lived iu tents. As comjjared with civilian 
practice one saw how much time was gained by the fact 
that there was no necessity to enter into lengthy explanation. 
The soldier, with few exceptions, receives his treatment with- 
out question, content that the best is being done for him, 
and, indeed, sometimes appears too machine-like. 

Proceeding, Captain Moorhead dealt with the type of case 
with which he was concerned in the medical division of the 
hospital, for the clinical supervision of which he was resj^ons- 
ible. An army had two foes — bacilli and bullets — and of these 
in most campaigns the former was by far the more dangerous. 
This probably did not hold good of our campaign in Fran2e. 
In Gallipoli, however, conditions were widely different, where 
our troops were holding on with difficulty to narrow strips 
of land, and where patients suffering from illness were often 
compelled from sheer lack of numbers to remain in the 
trenches for days before they could be evacuated bv sea 
to the base hospitals. Sanitary conditions also were had, 
and for this he thought to some extent the War Office was, 
perhaps, unavoidably to blame. From what he saw himself 
in his early days in Egypt he came to the conclusion that 
many newly-qualified men were sent out without receiving 
any instruction on camp sanitation. Probably the demand 
for men was so great and sudden that there was no time 
to give the necessary short course of practical lectures, but 
he felt certain that as soon as the first rush was over much 
would have been gained by organising practical instruction 
of the kind he had indicated. As it was, numerous men after 
joining the E.A.M.C. were kept at home during a few 
hours a day at hospital work, with which they were already 
familiar, and then perhaps sent out suddenly to look after 
units in the field. With the best intentions these men 
lacked the necessary experience of camp conditions, and at 
first, at any rate, were not in a position to deal effectively 
with the preventive side of medical war work. He ventured, 
therefore, to strongly urge that in the future a central depot 
should be established where practical information on all 
details of camp life could be given by regular officers of the 
E.A.M.C, and that all men on joining should be sent to 
the depot for at least a week before undertaking other work. 

In Gallipoli, of course, the tropical heat of the summer 



414 Biulogical Society of the R.C.S.t. 

months and the abundance of tlies made conditions es- 
pecially trying, but it was appalling to think that over 96,000 
cases of medical illness occurred, a total that was probably 
in some measure responsible for the failure of the campaign. 
The word enteric was now em])loved to indicate a group of 
diseases. These diseases which closely resembled one another 
in many im])ortant characteristics were produced by a group 
of allied bacilli. As far as his experience went anti-typhoid 
inoculation appeared to have been of great value, as only 
very few genuine typhoid cases were admitted to the hospital. 
Many soldiers were beginning to think that the process of 
vaccine was being overdone. The lot of the recruit was 
indeed a hard one. No wonder he was inclined to ask : 

When will the war be over '.'" He was, however, sufficiently 
sensible to realise that all these vaccines did no harm and 
that most of them had been proved to do good. 

Neurasthenic patients were very numerous, and the large 
majority were of necessity invalided home. The question was 
often raised as to what would become of these nervous wrecks 
when the war was over. For his part he was most hopeful, 
and thought that the existence in each case of an adequate 
cause for their breakdown was of itself ground for the belief 
that with the cessation of the cause they would, under favour- 
able circumstances, quickly and completely recover. They 
nmst not apply the gloomy lessons of neurasthenics in civil 
life to the war neurasthenia, now so })revalent. 

He hoped he had given a sufficient indication of what they 
were called on to deal with to prove to each student that if the 
war was going on still when he received his degrees his duty was 
to join immediately the K.A.M.C. He would find plenty of 
work waiting to be done that would enable him to feci that he 
was doing his part, as every Irisliman ought to do, in ihc 
defence of tlie Em))ire. Their roll of honour, he was })roud 
to say, showed that tlie College of Surgeons had already 
voluntarily adopted the i)rin('i|)le of conscription. Let them 
ho|)e that the nation as a whole would adopt it while ye* 
there was time. 

Sui'geon-Cieneral [•'•iid, iu proposing a \r)te of thanks to 
Professor Moorhead, (•((ngi'atulatcd their I'lcsidetit on hi-^ 
appointment as Consulting Surgeon to tlie i'^orces in Ireland. 

Mr. Hvu'st, Vice-Pi'esident of the .Vssocial ion, seconded the 
i'ote of thanks. 



li'mloijical Sucichj nj tJic 11. C.S.I. 415 

The President, in putting tlie resolution, referred to his 
own experiences in France in the earlv part of August this 
year, and said that during his visit to the base hospitals, 
the clearing stations, and the advanced dressing stations ha 
had seen the work being performed in France by the 
E.A.M.C., and lie felt gratified at what he saw. That 
work could never have been done, however, but for the 
assistance of the noble band of ladies of the Q.A.I.^I.N.S. 
and the V.A.D., and he took that opportunity of beariu'^ 
testimony to the splendid work of these ladies. Although 
there were millions of soldiers in France, their general health 
was twice as good as in these islands, and that was largely 
due to the influence of Preventive Medicine in connection 
with the Army Medical Service. The British soldier wms 
better treated at the base hospitals in France than he was 
in the best hospitals at h»me. 

Captain ]\loorhead briefly acknowledged the vote of thanks. 
The President said he was asked to present to. his Ex- 
cellency a copy of the Poll of Honour of the Royal College 
of Surgeons in Ireland. This Roll of Honour was not actually 
up to date. It was brouglit up to November of last year, 
but some improvements had been made recently, and so 
far as recent tigui-es were concerned, they had 1,012 old 
students in their Roll of Honour. Of these (3 had obtained 
the C.B., 12 the C.M.G., 22 the D.S.O., 18 the Military 
Cross, 1 the Croix Chevalier, and 111 were mentioned in 
despatches, many of them more than once. Whatever miglit 
be thought or said of the necessity of applying conscription 
to the youth of this country, he did not think there could 
be any question as to what that College had done for the 
Empire in the present crisis. 

His Excellency the Lord Lieutenant said he was very mucli 
obliged for the kind reception they had given him. He under- 
stood from a historical research, for which his friend SIl' 
Charles Cameron was responsible, that the connection be- 
tween the Royal College of Surgeons and the Lord Lieutenant 
in the past had been marked on more than one occasion 
by that friendly intercourse which had been partly responsible 
for calling them into existence. But he learned from tlie:r 
President that night that it was the first time a Lord Lieu- 
tenant had had the jn-ivilege of attending the annual 
meeting of the Biological Sociev of the College and of 



416 Biological Society of the R.C.S.I. 

hearing the annual address. He considered the occasion 
a very pleasing and fortunate one for him to meet so 
brilliant and distinguished a company and to listen to the 
address they had heard, and he assured them it was also a 
very great pleasure to him to be presented with their Koll 
of Honour in so handsome a form. There was no doubt it 
was a magnificent achievement to have such a number of 
past students of the College serving their country in one 
capacity or another, and the distinctions they had attained 
were such as the College could be very proud of. With regard 
to the lecture, he was afraid that for him it was far too 
technical, but most of those present would thoroughly ap- 
preciate the technical points, and would be all the better 
informed in consequence. Unfortunately he had not had the 
advantage of technical training, and therefore he was more 
or less in the character of a layftian. But he observed one 
thing in the course of the lecture, and that was the allusion 
of the lecturer to what he called " military shorthand." But 
when the lecturer came to giving a shorthand description 
of his owm technical subjects, the lecturer had offered to 
them a more interesting and significant shorthand system 
than he had ever heard expressed by any other authority. 
As an ex-politician, he was bound to say that when he heard 
N.Y.D. (Not Yet Discovered) he learned that there was a 
link between the medical and the political sphere of lif=5 
which he had never heard so well illustrated before. Con- 
cluding, his Excellency said he knew the great work their 
College had done, and he could only say he wished it well, 
and if it were possible for him at any time to be of service 
to them it \\iiuld be tlie greatest pleasure to him to give 
what assistance lie could. 

The meeting closed with the playing of the National 
Antbcni. 



ROYAL ACADEMY OF MEDICINE IN IRELAND. 



President— R. D. Purefoy, M.D., F.R.C.S.I. 
General Secretary— J. A. Scott, M.D., F.R.C.S.I. 



SECTION OF MEDICINE. 

President— H. C. Dkuky, M.D., F.K. C.P.I. 
Sectional Secretary- G. E. Nesbitt, M.D., F. II. C.P.I. 

Fridaij, Soveinbcr 3, 1916. 

The President in the Chair. 

PrcsidenVs Address. 

The President delivered an introductory Address dealing 
with the position and prospects of the Section, and pointed 
out various directions in which the work of the section might 
be improved and made more interesting and profitable. 
[The President's Address is published in full at page 370.] 

TJic AUen Trcatvtcnt of Diabetes. 

Dr. Nksbitt read a paper on the above, and showed a 
case treated by the met/hod. He detailed the procedure 
adopted to render and keep the urine sugar-free, and referred 
to the remarkable results obtained by American authors. 
The treatment was in many respects totally opposed to our 
previous conceptions of diabetes. [This paper appears at 
length at page 379.] 

The PREsmEXT asked whether the cases reported were in 
any way selected as being specially suitable for the treat- 
ment; also, how it succeeded in young subjects. 

Dr. Walter G. Smith considered that the fact that por- 
tions of the pancreas were left in the animal experiments 
vitiated the results. He had always divided the cases into 
two groups — the alimentary, which was easily controlled by 
suitable diet, and the endogenous, which manufactured sugar 
from body protein and was hopeless. Glycosuria was not 
really the important thing, but the amount of sugar in the 
blood. He thought we knew very little as yet of the meta- 



418 lloijul AcddcHiij of Medicine i)i Ireland. 

holism of sugar, and that it was often extremely dangerous 
to meddle. 

Dr. Moouiiead said that this method of treatment assumed 
that all eases of the disease were of the same type, whic'h 
had not been proved, and he thought was not the case. 
Many cases got on very well on the old lines ; and he would 
'hesitate to subject these to such a severe treatment. The 
three cases in which he had tried it all exhibited marked 
acidosis. He would be rather afraid of the result in feeble 
patients, and he would emphasise the point already noted l)y 
American authors — that i)atients who relapse are in a worse 
position for further treatment. 

Dr. Crofton referred to the use of hormonadin and other 
extracts of pancreas in the treatment of diabetes. He also 
drew attention to the frequency of focal infections — e.g., 
jiyorrhoea — and urged their appropriate treatment. 

Sir .John W. Moore disagreed altogether with the principle 
of this treatment. He objected to starvation on account of 
the fear of acidosis. A moderate allowance of carbohydrates 
often staved off a threatening diabetic coma. In addition 
to general hygienic measures he had nmch faith in cascara 
sagrada as a tonic aperient in the costiveness of the disease. 

Dr. Thompson related the facts of a case in which he had 
tried this method. The patient was a Jew, and did well 
wiiilc under observation, but had gone back to his former diet. 

l)i{. l'.\Rsoxs commented on the extraordinary claim that 
acidosis disa))peared during fasting. Had any explanation 
been f)ffi'i(Mr.' He had under treatment a very severe case, 
witii njari<cd acidosis, and he would like tf) know whether 
llie nietlinil should Ije tried. II' this pl;ui proved successful, 
\\f should liax'e lo re\oliit ionise oui' eoiieept ions of the disease. 

])\i. i>o\\vi;EL obji'cted to starvation prior to o})eration in 
diabetes on the gi'ound that it would increase acidosis. 

Dr. Bevvlev referred tf) the possible injiu'ious efl'ect on the 
nervous system. He also oi)jecte<l to the i<lea of tlie ))atients 
testing their own urine, 'i'hey would soon become hy])ochon- 
ilriacal or i)isane. 

i)U. I)a\\S(iN ;igree(l with I )f. liewlev, ntld thought SO 
Jinicli knowledge of their own c-ases would make patients 
depressed. 

Dr. Peacocki-; recalled a severe case in which he I'ailctl to 



\iir Prcihtraliints mul Sricntifir I iivoiiions. 411) 

get the urine sugar-free atter three days" last. Acidosis was 
present, and he did not persist further. 

Du. Nesiutt, in reply, said that this treatment had been 
evolved after an enormous amount of accurate scientific work. 
It was by no means a therapeutic fad. If it proved success- 
ful, and the results obtained in large numbers of cases by 
American observers were remarkable, we woidd certamly be 
compelled to revise our knowledge of diabetes. The case 
he 'had shown had proved perfectly amenable to treatment. 
Acidosis had disappeared, as well as sugar. There were no 
unusual mental symptoms. For the more severe cases some 
modification of the fat, as recommended by Joshn, would 
probably be necessary. Among the American cases no 
selectioiQ had been made, and young subjects seemed to do 
particularly well by this method. 



XEW PREPAKATIONS AND SCIENTIFIC INVENTIONS. 

" KEPLER "' COD ElVER OIL WITH MALT EXTRACT AND CREOSOTE. 

This product provides convincing evidence that "' Ivepler 
:\Ialt Extract, already recognised as a higlily nutritive and 
digestive preparation, is also of high value as a vehicle and 
tiavouring agent for nauseous medicaments. 

In " Kepler " Cod Liver Oil with :\Ialt Extract and Creo- 
sote, the medicaments are in intimate association with the 
vehicle. There is, consequently, no tendency towards separa- 
tion. Each fluid ounce contains 4 minims of creosote, and 
the dose is one teaspoonful to one tablespoonful. 

Physicians who, in the past, have experienced difficulty in 
administering cod-liver oil and creosote to their patients, 
will greatly appreciate this product. The rich nutty flavour 
of the " Kepler "" Malt Extract is distinctly evident, and 
renders the product acceptable even to tlie most fastidious 
judate. 

The name ot the Finn of Messrs. Burroughs, Wellcome 
i Co. is a guarantee of the quality of the materials used. 
" Kepler " Cod Liver Oil with Malt Extract and Creosote 
is particularly valuable in the treatment of phthisis. In ad- 
dition to providing an elegant preparation of cod-liver oil and 
creosote, wliicli ordinarily are tolerated with difficulty, the 
preparation supplies a food of high nutritive value. It is 
issued in l)ottles of one size only. 



SANITAEY AND ^lETEOEOLOGICAL NOTES. 

Vital Statistics. 
Fur four ivecks ending Saturday, November 4, lUlO. 

lEELAND. 

The average annual death-rate represented by the deaths-- 
exclusive of deaths of persons admitted into public institu- 
tions from without the respective districts — registered in 
the week ended Saturday, November 4, 1916, in the Dublin 
Registration Area and the eighteen principal provincial Urban 
Districts of Ireland, was 15.6 per 1,000 of the aggregate 
population, which for the purposes of these returns is esti- 
mated at 1,122,268. The deaths from all causes registered 
in the week ended Saturday, November 4, and during the 
period of four weeks ended on that date, respectively, were 
equal to the following annual rates per 1,000 of the po])u- 
lation: — 

Nineteen Town Districts, 15.6 and 15.8; Dublin Registra- 
tion Area, 15.9 and 17.4; Dublin City, 18.4 and 18. 7 ; Belfast, 
15.9 and 14.6; Cork, 12.2 and 18.6; Londonderry, 19.6 and 
17.6; Limerick, 23.0 and 21.0; and Waterford, 17.1 and 18.'). 
The deaths from certain epidemic diseases — namely, enteric 
fever, typhus, small-pox, measles, scarlet fever, whoo^jing- 
cough, diphtheria, dysentery, and diarrhoeal diseases— regis 
tered in the 19 town districts during the week ended Satur- 
day, November 4, were equal to an annual rate of 1.0 per 
1,000. Among the 119 deaths from all causes in Belfast 
were 1 from whoo])ing-cough, and 4 deaths of children under 
two years old from " diarrhoea and enteritis." Of the 18 
deaths registered in Cork 2 were of children under 2 years of 
age from " diarrhoea and enteritis." One death from measles 
is included among 9 deaths recorded in Waterford. Of 2 
deaths recorded in Ballymena 1 death was from diphtheria. 
Three deaths registered in Sligo include 2 from enteric fever. 

DUBLIN REGISTRATION AREA. 

The l)ul)1iii Iicgislralidii Aiva consists of the City of 
Dublin as extended by the Dublin Corporation Act, 1900, 
together with the Urban Districts of Rathmines, Pembroke, 
Blackrock and Kingstown. 'Vhr |)opulation of tlu" Area is 
;597,0()(). 

In th(! Dublin liegistration Area the births registered during 
the week ended November 4 amounted to 187 — 79 boys and 
108 girls, and the deaths to 127—05 males and 62 females. 



Sniiitanj nnd MctcomJogicnJ Notes. 421 

DEATHS. 

The deaths registered, omitting the deaths (numbering G) 
of persons admitted into pubhc institutions from locaHties 
outside the Area, represent an annual rate of mortahty of 
15.9 per 1,000 of tlie population. During the forty-four weeks 
ended with Saturday, November 4, the death-rate averaged 
19.7, and was 1.6 below the mean rate for the corresponding 
portions of the 10 years 1906-1915. The rate for all deaths 
registered during the forty-four weeks was 21.8, and in the 
corresponding period of the preceding 10 years it liad been 
22.5. 

The 121 deaths appertaining to the Area included 3 from 
enteric fever, and 5 of children under 2 years of age from 
diarrhoeal diseases. In the 3 preceding weeks deaths from 
enteric fever had numbei'ed 3^ 3, and 1 ; and deaths from 
diarrhoeal diseases of cliildren under two years old, 14, 13, 
and 11 respectively. 

Tuberculosis caused 16 deaths, as against 16, 18, and 20, 
respectively, in the three weeks preceding. Of the 16 deaths 
ascribed to tuberculosis, 14 were referred to ]iulmonary tuber- 
culosis, 2 to other forms of tuberculosis. 

Five deaths were caused by cancer, 13 by pneumonia 
(7 by broncho-pneumonia and 6 by pneumonia, type not 
distinguished), 17 by organic diseases of the heart, and 19 by 
l)ronchitis. 

Among deaths of infants under one year old, 5 were ascribed 
to convulsions, 4 to congenital debility, and 3 to prematurity. 

Six deaths were due to violence, 1 being caused by burns, 
and 5 by gunshot wounds. 

Thirty-six of the deaths registered during the week apper- 
taining to the Area were of children under 5 years of age, 30 
being infants under one year, of whom 10 were under one 
month old. 

Of the 121 deatiis recorded, 33 occurred in hospitals and 
other public institutions. 

STATE OF INFECTIOUS DISEASES. 

The following returns of the number of cases of Infectious 
Diseases notified under tlie "Infectious Diseases Notifica- 
tion Act, 1889," and the " Tuberculosis Prevention (Ireland) 



422 



Souitarij avd McteoroJocjk'al Notr.<^. 



Act, 1908," have been furnished by the respective sanitary 
authorities : — 



Table I. — Showing the Number of Cases of Infectious Diseases notified in the 
Dublin Registration Area— (viz., the City of Dublin and the Urban Districts of 
Rathmiues and Rathgar, Pembroke. Blackrock and Kingstown), and in the Cities 
of Belfast, Cork. Londonderry, Limerick, and Waterford, during the week ended 
November 4, 1916, and each of the preceding three weeks. 
A dash ( — ) denotes that the disease in question is not notifiable in the District, 



1 

Cities a.nd 
i'kiian disthiots 


Week 
' eniliu:; 

1 


1 






> 

u 

a 
v 
X 




5 


■§1 


> 

V > 




> 

2 

o 

p. 

S 


Wliooping-cougii 

Cereliro-spinal 

Fever 


_ r 
1 


B 
o 

-ft, 
S 


a 
c 

§1 

s 

An 


o 


City of Dublin | 

llilliiiiinosuiiil 1 
Uathgar j 

Dishrici I, 

I'oiubroke i 
Urban 

District | 

Blacl(roeU j 
Urban 
District 

Kingstown j 
Url)an 
District 

City of KelfttHt 

City of Corlc -J 

City of J.i.nil(.n- ( 
derrj i 

1 
City of l.iiiHiicU -j 

Cllyof WHtfrfo.cl 


Oct. U 
Oct. 21 
Oct. 28 
Nov. 4 

Oct. 14 
Oct. n 
Oct. 28 
Nov. 4 

Oct. 14 
Oct 21 
Oct. 28 
Nov. 4 

Oct. 14 
Oct. 21 
Oct. 28 
Nov. 4 

Oct. 14 

Oct. 21 
Oct. 28 
Nov. 4 

Oct. 14 
Oct. 21 
Oct. 28 
Nov. 4 

Oct. 14 
Oct. 21 
Oct 28 
Nov. 4 

Oct. 14 
cct. 21 
Oct 28 
Nov. 4 

Oct 14 
Oct. 21 
Oct. 28 
Nov 4 

Oct. 14 
0.1 21 

Oct J.s 
Nov. 4 




12 

14 
6 
'J 

3 

1 

i 

r 

1 

2t 

in 

20 
Hi 

2 
I 
2 

1 

3 

G 

8 

1 

i 


1 




1 

« 
4 

i 

2 

8 
4 

■2 

1 
2 

i 




2 
1 

3 


18 

18 
!l 

;i 
3 

i 

1 

1 

8 

1 

9 

i 

2 

1 

4 
7 
2 


1 
2 
4 




i 


i 
i 


1 


1 
i 


11 

;i 
8 
7 


48 
4,6 
2(i 
32 

2 
2 

i 
i 

i 

2 
3 

37 
18 
".6 
35 

2 

46 

4 

t; 

8 
10 

4 
2 

i 



a Continued fever, 



{) Not Including one ca«e of varlcelU, 



Sanitdrn h)ul Mctcorolotiical Notes. 



423 



Cases of Infectious Diseasks under Treatment in Dublin 
Hospitals. 

Table II. exhibits the number of cases of certain infectious 
diseases treated in the Dublin Hospitals during the week 
ended November 4, 1916, and the number under treatment at 
the close of each of the three preceding weeks. 

Table IL 





No. of Cases in Hospital 










Diseases 


at close of week ended 


Week 


ended November 4. 














No. 
















under 










i No. 


Dis- 


Died 


treat- 




Oct. 14 


Oct. 21 


Oct. 28 


admitted 


charged 




ment 
at close 


Enteric Fevor 














of week 


106 


107 


111 


8 


16 


2 


101 


Typhus 


:} 


3 


1 


2 


— 


— 


3 


Small-pox - 


— 


— 


— 


— 


— 


— 


— 


Measles - 


2 


2 


3 


— 


1 


— 


2 


Scarlet Fever 


61 


m 


67 


12 


13 


— 


66» 


Diphtheria - 


25 


19 


10 


3 


n 


— 


13 


Pneumonia - 


13 


16 


14 


9 


1 


I 


21 



" Exclusive of 1 s patients in " Beneavin," the Convalescent Home of Cork 
Street Fever Hospital. 

From this Table it appears tiiat the cases admitted to 
hospital during the week ended November 4, and the cases 
under treatment at its close, respectively, were as follow: — 
Enteric fever 8 and 101 ; typhus 2 and 3 ; measles and 
2 ; scarlet fever 12 and 66 ; and diphtheria 3 and 13. Nine 
cases of pneumonia were admitted during the week and 21 
remained under treatment at its close. Of the deaths in 
hospitals during the week 2 were from enteric fever, and 
1 was from pneumonia. 



424 Savifnrij nv(] M rtrorolndical Nntcfi. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, November 4, 
in 96 large English towns (including London, in which the 
rate was 12.8), was equal to an average annual death-rate of 
12. () per 1,000 persons living. The average rate for 16 prin- 
cipal towns of Scotland was 13.9 per 1,000, the rate for 
Glasgow being 13.3, and that for Edinburgh 14.6. 

Infectious Diseases in Edinburgh. 
The Registrar-General has been favoured by A. jMaxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for 
Edinburgh, with a copy of his Return of Infectious Diseases 
notified during the week ended November 4. From this 
Report it appears that of 46 cases notified, 16 were of scarlet 
fever, 7 of pulmonary tuberculosis, 7 of other forms <^f 
tuberculosis, 14 of diphtheria, and 2 of erysipelas. Among the 
398 cases of infectious diseases in hospital at the close of 
the week were 139 of pulmonary tuberculosis, 137 of scarlet 
fever, 77 oi diphtheria, 7 of measles, 4 of enteric fever, 3 
of whooping-cough, 2 of cerebro-spinal fever, 1 of erysipelas, 
and 1 of puerperal fever. 



Meteorology. 
Abstract of Observations made in the Citif of Dnhlin,, Lat. oS'' 20' 

N., Long. 6^ 15', for the Month of October, 1910. 
Mean Height of Barometer, - - - 29.693 inches. 

Maximal Height of Barometer (19th, at 9 p.m.), 30.250 „ 
Minimal Height of Barometer (30th, at 2 p.m.), 28.591 „ 
Mean Dry-bulb Temperature, - - - 51.9°. 

Mean Wet-bulb Temperatuie, - 49.6°. 

Mean Dew-point T3nipcrature, - - 47.3°, 

Mean Elastic Force (Tension) of Aqueous Vapour, .332 inch. 
Mean Humidity, . - - . 35.3 p^r cent. 

Highest Toinperatare in Shade (on 6th), - 69.0°. 

Lowest Temperature in Shade (on 16th & 30th), 40.3°. 
Lowest Temperature on Grass (Radiation) (27th) 33.9° 
Mean Amount of Cloud, - - 69.7 per cent. 

Rainfall {on 24 days), - - - - 5.951 inches. 

Greatest Daily liainfall (on 2h(1), 0.793 inch. 

General Directions of Wind, - - - VV., S.W., 8.E. 



Smiitanj and Mrfrnrnloqiral Nofrsi. 425 

Rf marks. 

The chief features of the weather in October, 1916, were a 
high temperature lasting throughout the first two weeks 
(lst-14th), very uiisettled weather with frequent oscillations 
of atmospheric pressure, severe gales and heavy rainfalls 
during the second half of the month. Much cloud prevailed, 
and the rainfall was particularly heavy in the daytime (9 a.m. 
to 9 p.m.) — namely, 3.179 inches, or 53.4 per cent, of the total 
precipitation for the month. The strong winds and gales wevd 
from southerl}^ points. The mean temperature of the first 
fortnight was as high as 58.1°, that of the second fortnight 
(15th-28th) was 48.5°— a falling off of nearly 10 degrees. 

Very low pouits were reached b}^ the barometer in the gales 
of the 25th (28.800 inches), 27th (28.740 inches), and 30th 
(28.591 inches) — the minimal atmospheric pressure of the 
month. 

The mean height of the barometer was 29.693 inches, or 
0.147 inch below the corrected average value for October — 
namely, 29.840 inches. The mercury rose to 30.250 inches 
at 9 p.m. of the 19th, and fell to 28.591 inches at 2 p.m. of 
the 30th. The observed range of atmospheric pressure was, 
therefore, 1.659 inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 51.9°, or 
3.7° below the value for September, 1916. The arithmeUcal 
mean of the maximal and minimal readings was 52.9°, 
compared with a thirty-five years' (1871-1905) average of 
49.5°. Using the formula. Mean Temp. = Mi7i. -f- (Max. — 
Min.) X .485, the mean temperature was 52.7°, or 3.4° above 
the average mean temperature for October, calculated in 
the same way, in thirty-five years, 1871-1905, inclusive 
(49.3°). On the 6th the thermometer in the screen rose to 
69.0°— wind, S.S.W. ; or the 16th and 30th the temperature 
feU to 40.3°— wind, W. on the 16th, S.S.W. on the 30th. The 
minimum on the grass was 33.9°, on the 27th — wind, N. 

In Dubhn the mean maximal temperature was 57.5°, com- 
pared with the average (54.7°) ; and the mean minimal 
temperature was 48.2°, compared Avith the average, 44.3°. 
The arithmetical mean temperature (52.9°) was 3.4° above the 
average (49.5°) ; the mean dry-bulb readings at 9 a.m. and 
9 p.m. were 51.9°. In the fifty years ending with 1915, October 

2 H 



426 Sanitarij and MefeoroJocjicnl Notes. 

was coldest in 1892 (M.T. = 44.8°) and in 1896 (M.T. = 45.0°). 
It was warmest in 1908 (M. T. = 55.4°) and in 1912 {M. T. = 
54.9°). In 1913, the M. T. was 52.2°, in 1914, 52.5°, and in 
1915, 49.8°. 

The rainfall was 5.951 inches, distributed over 24 days. 
The rainfall and the rain-days were much above the average. 
The average rainfall for October in the thirty-five years, 1871- 
1905, inclusive, was 2.870 inches, and the average number of 
rain-days was 18. In 1880 the rainfall in October was very 
large — ^7.358 inches on 15 days. In 1875, also, 7.049 inches 
fell on 26 days. On the other hand, in 1904, only 0.454 inch 
fell on 11 da -s ; in 1890 only 0.639 inch fell on but 11 days, in 
1884 only 0.834 inch on but 14 days, and in 1868 only 0.856 
inch on 15 days. In 1911, 3.787 mches were recorded on 20 
days ; in 1912, 1.665 inches on 13 days ; in 1913, 3.760 inches, 
on 17 days ; in 1914, 1.244 inches on 12 days ; and in 1915 
4.807 inches on 19 da^^s. 

High winds (force 4 to 7) were noted on 18 days, and on 
8 days (6th, 7th, 10th, 14th, 24th, 25th, 27th and 30th) attained 
the force of a gale (force 8 or upwards). The atmosphere was 
foggy in Dubhn on the 13th. There were lunar halos on the 
7th and 9th, a lunar corona on the 10th, and a solar halo 
on the 16th. Lightning was seen on the night of the 5th, 
and thunder was heard on the 7th. Hail fell on the 15th. 

The rainfall in Dubhn during the ten months ending October 
31st, 1916, has amounted to 30.123 inches on 190 days, com- 
pared with 24.979 inches on 169 days in 1915, 17.071 inches on 
152 days in 1914, 24.742 inches on 157 days in 1913, 24.323 
inches on 171 days in 1912, 16.386 inches on 140 da.ys in 1911. 
27.330 niches on 177 days in 1910, 21.106 inches on 158 days 
in 1909, 12.366 inches on 123 days during the same period in 
1887 (the dry year), and a thirty-live years' (1871-1905) 
average of 23.030 inches on 164 days. 

Mr. T. MiUock Bentley reports that at the Normal Climato- 
logical Station in Trinity College, Dubhn, the mean value of 
the readings of the dry-bulb thermometer at 9 a.m. and 9 p.m. 
was 53.1°. The arithmetical mean of the daily maximal and 
minimal tom])eratures was 52.9°. The screened thermometers 
rose to 70" on the 3rd and fell to 39° on the 24th, 2()th, and 
30th. On the 2()tli tiie grass minimum was 28°. Rain fell 
on 24 days to the amount of 5.748 implies, the greatest fall in 



SauHary ant] MctvoroJiXjicnl Notes. 427 

24 hours being 0.734 inch on the 2nd. The mean temperature 
of the soil at a.m. at a depth of one foot was .~)4.2'' ; at a depth 
of 4 feet it was 55.2°. The duration of bright sunshine was 
65.4 hours, or a daily average of 2,1 hours. On the 25th there 
were 7.4 hours of sunshine. 



Captain Edward Taylor, D.L., returns the rainfall at 
Ardgillan, Balbriggan, Co. Dublin (height above sea level, 
210 feet), as 7.33 inches on 24 days, the largest measurement 
in one day being 1.31 inches on the 2nd. This was the greatest 
monthly rainfall recorded at Ardgillan witliin the past 23 
years, and, of course, estabhshes a record for October. The 
rainfall was 4.61 inches above the average, and the rain-days 
were 7 in excess of the average. From January 1 to October 31, 
the rainfall at Ai'dgillan has been 29.92 inches on 184 days 
or 6.52 inches above the average, while the rain-days were 
31 in excess of the average. The highest shade temperature 
in October was 67.7° on the 6th ; the lowest was 37.9° on the 
30th. 

At Stirling, Clonee, Co. Meath, Mr. J. Pilkington registered 
a rainfall of 8.00 inches on 26 days, the largest daily measure- 
ments being 0.95 inch on the 27th, 0.86 inch on the 2nd, and 
0.82 inch on the 13th. From January 1 to October 31, 1916, 
rain fell on 195 daj's to the amomit of 34.80 inches. This 
station stands 231 feet above sea-level. October 1916 estab- 
hshes a record for rainfall at Stirhng, Clonee. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. DubUn, was 6.17 inches on 23 days, the greatest 
fall in 24 hours being 0.885 inch on the 2nd. We must go 
back to August, 1912 (6.39 inches) and August, 1905 (7.18 
inches) for similar amomits of rainfall in a month. 

At the Royal Botanic Gardens, Glasnevin, rain fell on 27 
days to the amount of 6.32 inches, the greatest dail fall 
being 0.73 inch on the 2nd. 

At the Ordnance Survey Office, Phoenix Park, Dublm, the 
October rainfall was 6.610 inches on 25 days. The heaviest 
fall in 24 hours was 0.716 inch on the 13th. The total amount 
of bright smishine was 58.6 hours, the maximal duration on 
any one day being 8.6 hours on the 26th. 

Mr. F. C. Joynt registeied 5.585 inches of rain on 24 days 



428 Sanitary and Mctcorolofiiral Notes. 

at 89 Anglesea Road, Donnybrook, Dublin, the largest measure- 
ment in 24 hours being 0.720 inch on the 2nd. The ther- 
mometer rose to 70° on the 3rd and fell to 40° on the 15th 
and 29th. 

The rainfall recorded by Miss Mary Love at Cheevorstown 
Convalescent Home, Clondalkin, Co. Dublin, was 0.86 inches 
on 27 days. The heavies fc rainfall in 24 hour'; was 1.05 inches 
on the 27th 

Dr. Arthur S. Goff reports that rain fell on 27 days at 
Belfort House, Dmidrum, Co. DubUn, the total amount being 
5.62 inches, of which 0.70 inch was measured on the 13th. 
The temperature range was from 70° on ihe 6th to 40° on 
the 29th. The mean temperature in the shade was 53.0°. 

Mr. W. J. McCabe, on behalf of the Right Hon. Laurence 
P. Waldron, D.L., returns a rainfall of 5.29 inches on 21 days 
at Marino, Killiney, Co. Dublin. The heaviest fall in 24 hours 
was 0.69 inch on the 2nd. On the 14th, 0.61 inch fell, and 
on the 29th, 0.52 inch. The average October rainfall at 
Cloneevin, Killirey, in the 24 years, 1885-1908, was 2.985 
inches on 17.2 days. 

Mr. Harold Fayle sends the following report for October 
from Sandford Lodge, Ranelagh, Dublin (height of rain-gauge 
above mean sea-level, 66 feet ; above ground, 11 inches) : — 

Mean corrected Height of Barometer, - 29.703 inches 

Highest corrected Reading {19th, 21 hours). - 30.25 ,, 

Lowest corrected Reading (30th, 9 hours). - 28.85 

Mean Dry-bulb Temperature, - - - 52.3°. 

Mean Wet-bulb Temperature, - - 50.2°. 

Mean Maximal Temperature, - - - 58.0°. 

Mean Minimal Temperature, - - - 47.2°. 

Arithjnetical Mean Temperature, - - 52.6°. 

Highest Temperature in Screen (6th), - 70°. 

Lowest Temperature in Screen (24th), - 37°. 

Lowest Temperature on Grass (24th, 27th), - 26°. 

Nights of Ground Frost - - - 4 

Rainfall (on 24 days), - - - - 6.02 inches 

Greatest Daily Rainfall (2n(l). - - 0.73 inch. 

Mean Amoutit of Cloud, - - - 78 per cent. 

Days of Clear Sky, - - - - 2 

Days of Overcast Sky - - - 20 



SiDiitanj and Mctcuivlugical Notes. 429 

At Coolagad, Greystones, Co. VVicklow, Dr. John H. M . 
Armt^trong, M.B., measured 7.16 inches of rain on 24 days, 
the maximal falls in 24 hours bemg 0.92 inch on the 2nd, 
0.84 inch on the 29th, and 0.74 inch on the 26th. Gales pre- 
vailed on the 14th, 24th and 30th. From January 1 to 
October 31, 1916, the rainfall at Coolagad amounted to 36.58 
inches on 188 days. 

]\Irs. Sydney O'Sulhvan recorded 5.50 inches of rain on 
25 days at Auburn, Greystones, Co. Wicklow, the greatest 
rainfalls in 24 hours being 0.87 inch on the 2nd, 0.55 inch 
on the 3rd, and 0.62 inch on the 29th. 

Dr. F. O'B. Kennedy, Resident Medical Officer, reports that 
6.43 mches of rain fell on 26 days at the Royal National 
Hospital for Consumption for Ireland, n?ar Newcastle, Co. 
Wicldow. The maximum in 24 hours was 1.00 inch on the 
2nd. The mean temperature of the month at the Hospital 
was 51.5°, the extreme readings of the shade thermometer 
being— highest, 69° on the 3rd ; lowest, 34° on the 30th. 
The mean maximal temperature was 57.1°, the mean minimum 
was 45.8°. 

The Rev. Canon Arthur Wilson recorded a rainfall of 13.42 
inches on 29 days at the Rectory, Dunmanway, Co. Cork. 
October 1916 proved to be the wettest month in the past 
12 years except December, 1914, when the fall was 14.02 inches. 
The fall on October 1st of 2.52 inches is a record, the nearest 
approach being 2.04 inches on November 14, 1911. No less 
than 5.67 inches fell on the first five days. It was a very mild 
month. Frost occurred on the nights of the 24th and 25th 
only. The last week was colder and ver\^ stormy, especially 
on the night of the 26th and the morning of the 30th. The 
heaviest daily falls in the month were 2.52 inches on the 1st, 
1.58 inches on the 2ist, 1.46 inches on the 5th, 0.88 inch on 
the 26th, 0.76 inch on the 22nd, and 0.70 inch on the 3rd. 
The total rainfall for the completed 10 months of 1916 is 
49.47 inches, compared with an average for the past 12 years 
of 46.21 niches, and a fall of 51.53 inches in 1915. 



(n Mcmariam. 



EOBEET LAFAYETTE SWAN, L. E.G. P. I., 
F. E.G. S.I. 

BoRX April 27, 1843. Died November 4, 1916. 

With deep regret we record the death of Eobert 
Lafayette Swan, Fellow and ex-President of the Eoyal 
Gollege of Surgeons in Ireland, which occurred at his 
residence, Delaford, Gounty Dublin, on Saturday, 
November 4, 1916. 

EoBERT SwAX came from a stock that had long been 
resident in Ireland. A scion of this family, the Eev. 
Bellingham Swan, was curate to Dean Swift in St. 
Patrick's Gathedral, and afterwards Vicar of Desert 
Serges, Gounty Gork, where he died, in October, 1798, 
at the age of ninetj'-six. Eobert Swan's father, John 
Wright Swan, studied medicine in Dublin in the early 
part of the last century, and qualified as Licentiate of 
the Apothecary's Hall in 1834, and as Member of the 
Eoyal College of Surgeons, England, in 1835. He was 
then ap])ointed Medical Officer of the Castle Durrow 
Dispensary, Queen's Gounty, and while there his eldest 
son, Egbert, was boni, on April 27, 1843. Shortly after 
tile birth of liis son, John Wright Swan was elected 
Medical Officer of the Ballyragget Dispensary, Gounty 
Kilkenny, a position whieh lie held till his death, some 
thirty years later. It was at Ballyragget that Egbert 
SwAX i)assed his early days, and he was educated at the 
Kilkenny Grammar School, which had been founded in 
llic seventeenth century by the great Duke of Ormonde. 
On Noveml)('r 17, I8r)9, young Swan eiitcud tlu' Medieal 
School of D)-. Steeveiis' Hosj)ital. This school had been 
established ut the Hospital in 18r)7, in accoiihuicc with 
till' fccoinmcndatioiis mad(> by the Commission a|i|>ointr(l 



$tt ftlcmonam. 



to consider the grants made to certain Dublin Hospitals. 
The teaching of anatomy there had been entrusted to 
Edward Hamilton and Samuel A. Cusack, and Swan at 
once started dissecting under the tuition ot Hamilton. 
He proved himself an able and an attentive student, and 
at the end of his fourth winter session obtained the senior 
prizes of his year, the silver Cusack Medal and the senior 
Clinical Surgical Prize. In June, 1863, he was admitted 
a Licentiate of the Eoyal College of Surgeons in Ireland. 
He was then just twenty years of age, and had to wait 
till the following year, when he reached the age of 
twenty-one, before he was admitted a Licentiate of the 
King and Queen's College of Physicians. 

The minutes of the School Committee bear generous 
testimony to the brilliance of Swan's career at Steevens' 
Hospital, and inmiediately after he was qualified he was 
unanimously recommended to the Board of the Hospital 
for appointment as Curator of the Hospital jSIuseum. 
In this capacity he worked hard in arranging and 
describing the specimens, and the manuscript catalogue, 
still preserved in the Hospital, is a proof of his industry 
and of his wide knowledge of macroscopic pathology. In 
September, 1867, he relinquished the post of Curator on 
being appointed Eesident Surgeon in the Hospital, a post 
of considerable importance and responsibility. The 
Eesident Surgeon at Steevens' Hospital occupied a some- 
what different position from similar officers in other 
Dublin Hospitals. Beside the general supervision of the 
Hospital he was allowed to take pupils, and some of the 
surgical beds were placed under his sole charge. Both 
Abraham Colles and William James Cusack were Presi- 
dents of the Eoyal College of Surgeons in Ireland while 
Eesident Surgeons at Steevens' Hospital. In 1868 
Swan was admitted a Fellow of the College of Surgeons, 
and on his resigning his Eesident Surgeoncy, after two 
years in office, he was again elected Curator of the 
Museum. In 1868 Swan took a liouse at 11 Usher's 
Island, and settled down to make for himself a practice 
as a surgeon. As was the habit in Dublin for young 
medical men, he started as a private medical teacher, 



-r 



in Mfnxovimxu 



and, in conjunction with Richard Bookey, another 
Steevens' student, opened class-rooms at No. 1 Great 
Brunswick Street. Practice came quickly, and he was 
appointed Assistant Surgeon to the Royal Irish Con- 
stabulary, and Surgeon to the employees of the Great 
Southern and Western Eailway Company. In 1873 he 
was appointed Lecturer in Anatomy in the Steevens' 
School in the place of Robert McDonnell, who had been 
appointed to the Court of Examiners in the College of 
Surgeons, ' and he held this post till he was himself ap- 
pointed to the Court in 1877. 

While teaching anatomy at Steevens' Hospital Swan 
became interested in orthopaedic surgery. He saw that 
there was an opening in Dublin for such \v'ork, and deter- 
mined to avail himself of it. He recognised that to 
succeed special study was necessary, and also that special 
facilities for the treatment of the patients would be 
required. He had not at the time the comixiand of any 
hospital beds, and even if he had, he saw that a general 
hospital was not a suitable place for tlic treatment of 
such patients, who would require for their cure a con- 
tinuous treatment extending over many months. To 
meet this difficulty, he decided on the bold course of 
founding a s])eeial hospital for the treatment of (jrtho- 
])cedic cases. He interested a few friends in his scheme, 
and on July 6, 1876, a meeting was held in his house on 
Usher's Island, at wliich was founded the Dublin 
Orthopaedic Hospital. The hospital was opened for the 
reception of six patients in that house (hu'ing the follow- 
ing October. From the outset the hospital was a 
success, botli surgically and financially, and in both 
respects Sw.an was the leading figure. His house, 11 
Usher's Island, was given u]) to the hosiiital ; his sul)- 
scriptions in money were liberal and many; and bis 
surgical skill was devoted without stmt to tlie l)enefit 
of the patients. In 1884 the liospital was Itausfei timI to 
new premises in Great lirunswick' Sticcl, wliicb bad 
formerly been ()ccu|)ied by Hood's Hotel, and in 1002 
it was moved to its present siti' in U]»per Mevrion Street, 
where for some years past the daily luunbiT of beds 



in Mtmoviam, 



occupied has been over seventy. Ever since its founda- 
tion 8wAN has devotedly served the Orthopaedic Hos- 
l)ital. He set apart a room in his private house in the 
country as a convalescent ward for the patients ; he pro- 
vided premises, rent free, for the hospital laundry; and 
he supplied the hospital with vegetables from his garden 
at considerably below their market value. He held the 
()I)iiiion that in the feeding of children, especially those 
suffering from rickets, it was important that the milk 
given to them should not be taken from cows that were 
at the time carrying calves. The milk from such cows, 
he believed, was deficient in important constituents that 
were used up by the developing calf. For several years 
he conducted a dairy farm so as to enable him to supply 
the hospital with suitable milk. There is no doubt that 
the wide support that the hospital has gained through- 
out the country is chiefly, if not entirely, due to Swan's 
skill as an orthopaedic surgeon. 

While Swan will be chiefly remembered as the leading 
orthopaedic surgeon of his time in Ireland, he did not 
devote himself exclusively to that specialty. In 1891 
he was appointed Visiting Surgeon to Steevens' Hos- 
pital, and in 1898 and 1899 the Fellows of the Royal 
College of Surgeons in Ireland elected him President of 
tlieir College. As a surgeon, he seemed to be endowed 
with that clinical insight that leads at once to accurate 
diagnosis and successful treatment. His knowledge of 
anatomy and general pathology, together with his power 
of co-ordinating and visualising his long clinical ex- 
])erience, made his opinion on an obscure case par- 
ticularly valuable. To the end of his life he was a great 
reader, and had the faculty of selecting and retaining 
from what he read those things that were useful to him. 
One was often surprised by the accurate knowledge that 
he possessed of recent surgical work. As an operator, 
he was rapid, and full of resource in the presence of 
difBculties, and though his methods sometimes appeared 
to l)e rough, they were guided by a skill and a knowledge 
that robbed that roughness of its danger, and all such 
roughness was laid aside when delicacy of manipulation 



in MtwxQvimw* 



became a condition of success. Trained in the old school 
of surgery, he adapted himself readily and easily to every 
modern improvement, while he always retained that 
dexterity and rapidity of working which were so charac- 
teristic of men like Robert McDonnell and Edward 
Hamilton. 

Physically Swan was a fine specimen of manhood. 
Somewhat above middle height, he was powerfully 
built, and his massive head was thickly covered with 
dark hair, which showed only slight greyness at the time 
of his death. He never required glasses while operating, 
having escaped almost entirely from presbyopia. His 
energy seemed to be inexhaustible. Some years ago he 
thought nothing of doing several major operations at the 
hospital in the morning, then riding 15 or 20 miles to a 
hunt, and after hunting till dark then riding home again. A 
few weeks before his fatal illness, on being advised to 
lead a less strenuous life, he replied that he had ridden 
ten miles on his bicycle that morning before his break- 
fast without discomfort. He lived abstemiously, and 
seldom ate anything between his early breakfast and his 
late dinner. He walked little, but was at home on 
liorseback in any country. His motor car and his bicycle 
he used merely as means of conveyance. 

Just as strength was Swan's chief physical charac- 
teristic so it was also the most prominent feature of his 
character. Neither oi)position nor difficulties ever 
deflected him in the slightest from the course he had 
detennined to adopt. When he considered his actions 
rigiit, he never bothered about criticism, and what others 
\\-ould say or think of him never entered into his cal- 
cidations. Whether people spoke well of him or ill was 
(■(lually a matter of indifference, and he never seemed to 
hear any enmity against those w'ho spoke against him. 
He was sparing of his criticism of others, and though he 
might criticise opinions tliat he disagreed with he never 
attacked the indix i(hial who had (.'xpressed tliose opinions. 
While easy to become acquainted witli, he was difficult 
to know, and even to his friends he was reserved. His 
even temper jind |)iiih)so|)iiic disposition were the result 



ftn iWrmonam. 



of his wonderful self-control rather than of his tempera- 
ment. Just as in appearance he never grew old, so to 
the end of his life his mind retained the receptiveness 
of youth. He was always ready to assimilate a new- 
idea, and his surgery never became stereotyped. Of late 
years he travelled much, and always came home 
with some new ideas, which, no matter how revolu- 
tionary, were critically examined with a perfectly open 
mind. The continuous open-air treatment of patients, 
which he introduced at the Orthopaedic and Steevens' 
Hospitals, he tried first on himself by sleeping for many 
months in a small open shed in his garden, where a 
neighbouring stream provided him with his morning tub 
and a perforated bucket suspended from an overhanging 
tree was used as a shower bath. Another notable in- 
novation introduced by him at the Orthopaedic Hospital 
was the establishment of a school for the children. 
:\Iany of these children have to spend months in hospital, 
confined to bed on account of their deformities, but not 
otherwise sick. These children are now provided with a 
school teacher under the Board of National Education, 
so that their education is not interfered with by their 
stay in hospital. The plan has proved a brilliant success 
from every point of view. As a teac'her, Swan gave 
instruction rather by what he did than by what he said, 
and to act as his dresser was a privilege eagerly sought 
for by the pupils of the hospital. W'hile never seeking 
popularity, Sw.\x was liked by all who knew him, and 
the better one knew him, the more one liked him. He 
was a true and loyal friend, a genial and kindly host, 
and a delightful and interesting companion. By 'his 
death Dublin has lost a notable personality, orthopaedic 
surgery in Ireland has lost its chief exponent, and many 
of us have lost a dear fnend. 

While Eesident Surgeon ni Steevens" Hospital Swan 
married the widow of Judge Teed. She died some years 
ago, leaving an only son, John Stewart Swan, at present 
Lt. -Colonel in tlu- Indian Army. 

T. P. C. K. 



$u Mcmonam. 



Bibliography. 

Intra-Uterine Fractures. Med. Press and Circular, 
February 26, 1879. P. 160. 

Spinal Caries : Some of its jMost Connuon Results and 
their Treatment. Med. Press and Circular, April 5, 
1882. P. 287. 

Tubercular Diseases of the Hip Joint. Med. Press 
and Circular, January to December, 1896. Pp. 157, 
181, 231, 315, 496, 80, 355. 

The Treatment of Tuberculous Disease of the Hip 
Joint. Med. Press and Circular. Vol. 115. P. 51. 
1897. 

A Method of Treating Certain Conditions of Joints. 
Med. Press and Circular. Vol. 124; page 102. January 
29, 1902. 

Congenital Dislocations of the Hip : With Cases in 
Illustration of Its Treatment. (Associated with Walter 
C. Stevenson.) Med. Press and Circular. Vol. 143; 
p. 193. August 23, 1911. 

Modified Splint for the Treatment of Fracture of 
Fibula, with Lateral Luxation. Dub. Quart. Journ. 
Med. Science. Vol. XLVII. ; p. 50. February, 1869. 

Pleuro-Pneumonia, followed by General Emphysema. 
Dub. Juurn. i\led. Science. Vol. LX. ; p. 476. Novem- 
ber, 1875. (A clinical record.) 

Wry Neck, Its Phases and Treatment. Dub. Journ. 
Me.l. Science. Vol. LXVIII. '; p. 114. August, 1879. 
(One plate.) 

A Boot Wliich Allows Walking, and Maintains the 
Foot in Good Pusition During the Treatment of Equino- 
X'arus. Dub. Journ. Med. Science. Vol. LXIX. ; 
p. 191. March, 1880. 

The Treatment of Genu N'algum by Cuiidylotomy with 
the Chisel. Dub. Journ. Med. Science. Vol. LXX. ; 
p. 165. December, 1880. (Five ])lates.) 

Caries of the Spine. Dul). Journ. Med. Science. 
\()l. X('\'.; p. 155. .\ugust, 1893. (A clinical record.) 

X'cnercal Diseases and Their Therapeutics. Dub. 
• loiini. .Med. Science. Vol. CVIII.; p. lOl. December, 
bS99. 

( 'oii(l\ lotniiiy \i\ the Osti'oionu' lor the Trt'atnient of 
l\nocl\ Knee. 'I'lans. lioy. Acad. Med., Ireland. Vol. 
111.; 11. 1H.'5. IH85. (TJccord of 68 palienls treated.) 



$11 iWcmortam. 



The Treatment of Advanced Conditions of Eqnino- 
Varus. Trans. Roy. Acad. Med., Ireland. Vol. VI.; 
p. 121. 1888. (Eleven plates.) Ibid. Dub. .Tourn. ^led. 
Science. Vol. LXXXVI. ; p. 177. September, 1888. 

The Treatment and Origin of Hammer Toe. Trans. 
J\ny. Acad. Med., Ireland. Vol. X.; p. 174. 1892. 

A New Operation for Rotation Inward of the Entire 
Jjinib after .\ggravated Equino-Varns : With an 
Attempt to Explain the Anatomy and Etiology of the 
Distorsion. Trans. Roy. Acad. Med., Ireland. Vol. 
XIII. : II. 195. 1805. 

Ibid. Dub. Journ. l\Ied. Science Vol. C. ; p. 200. 
October, 1895. 

Presidential Address, Delivered in the Section of 
Surgery of the Royal Academy of Medicine in Ireland. 
November 11, 1898. Trans. Roy. Acad. ^led., Ireland. 
Vol. XVII. ; p. 180. 1899. 

Presidential Address, Delivered in the Section nf 
Surgery of the Royal Academy of IMedicine in Ireland, 
November 10, 1890. Trans. Roy. Acad. ^led., Ireland. 
Vol. XVIII. ; p. 110. 1900. (On the Prevention and 
Treatment of Syphilis.) 

Attached Foreign Body in the Knee-Joint Removed 
bv Section of the Patella. Trans. Roy. Acad. Med., 
Ireland. Vol. XVIII. ; p. 143. 1900. 

A Method of Treating Certain Conditions of the Knee- 
joint. Trans. Roy. Acad. Med., Ireland. Vol. XX.; 
p. 143. 1902. 

Manual of Diseases and Deformities of the Spine. By 
R. L. Swan. With thirty-t;hree lithographic illustra- 
tions. Dublin: Fannin & Co. 1894. 8vo. Pp. xvi. 
and 194. 

Congenital Dislocation of the Hip, with Cases in 
Illustration of its Treatment. By R. L. Swan, 
F.R.C.S.I., and Walter C. Stevenson, M.D. Re- 
printed from the Medical Press and Circidar, August 23, 
1911. London: Bailliere, Tindall & Cox. 1911. 8vo. 
Pp. 18. 

Spinal Caries : Some of its Most Common Results, 
and their Treatment. By R. L. Swan. Reprinted 
from the Medical Press and Circular. ^'ol. XXXIII. 
1882. London. 1882. 8vo. Pp. 12. 



(n Illttmoriam. 



JOHN TODHUNTER, 

M.D., D.P.H., Univ. Durl. 

Probably quite unknown to the present, and, i3erclianee, 
half forgotten by tlie passing generation of JNIedical 
Practitioners in Dubhii, the name of John Todhuxtkk 
remains a Hving memory to the writer of these few hnes 
of tribute to a hfe-long friend. 

Born in Dubhn in the year 1839, and therefore in his 
seventy-seventh year at the time of his deatli on October 
25th, 1916, John Todhunter came of a sturdy Enghsh 
and Quaker stock.- His father was Thomas Harvey 
Todhunter, a DubHn merchant, long resident on Sir 
Jolui Eogerson's Quay in this city. In the fine old 
dwelling-house in that much changed locality, young 
Todhunter spent his childhood. He was educated at the 
Friends' School, York, and afterwards at Trinity College, 
Dublin, taking the degrees of M.B. and M.Ch in the 
University of Dublin in 1867. In 1869, he became a 
Licentiate of the King and Queen's College of Physi- 
cians in Ireland, and in 1871 he took the M.D. Degree 
of the University on passing the first examination ever 
held for the newly-instituted Diploma in State Medicine. 
His fellow-candidates for the diploma were the late Dr. 
Arthui' Wynne I'oot, the late Professor Gerald 1^'rancis 
Yeo, and tlie wi'iter — now tbe ftnly sinvivoi' of tlu' 
(juartet. 

Dr. TonnuxTioH, after ()l)taining his (|ualifications, 
shidiod for some time in Vienna and Paris. Peturning 
lo Dublin, lie commenced practice as a physician, and 
in due time was a])))ointod Visiting Physician to Cork 
Street l''evcr Hospital and House of Pecovevy, as well 
as to the I-'riends' Retreat Hospitnl, Dublin. In these 
ii)s1 iUit ions he did good woi'k. 



$n Atrmovtam* 



But liiterature and Poetry had already marked him 
for their own, and he yielded to the spell of their clarion- 
call. Dr. Todhuxtkr was Professor of English Litera- 
ture in the Alexandra College from 1870 to 1874. In 
the latter year he left Dublin for London, in which he 
made his permanent home — a home that became a 
resort for artists and men of letters through many a 
succeeding year. 

This is not the place to enlarge on Dr. Todhuxtf.r's 
literary and poetic powers, but two or three sentences 
may well be culled from an appreciating obituary notice 
which appeared in The Times of October 27th. They 
run as follows : — 

" Todhuxter's first volume was a collection of narra- 
tive and lyrical poems entitled ' Laurella " (1876). 
Grace, tenderness, and melody marked these poems; in 
later years he did much stronger work under the in- 
fluence of ancient Celtic literature, to the study of which 
he was led by the memorable rendering of the Cuchullin 
legend published in 1878 by Standish O 'Grady. ' The 
Banshee " (1888) and ' Three Bardic Tales ' (1896) con- 
tain the best of Todhuxter's work in poetry." 

One is tempted here to quote the third and last stanza 
in " A Song of Sustainment, " published in 1876: — 

"Faint and weary, wait on God patiently: 

It may be 
He would have thee stand and wait. 
Till He ope for thee a gate 
Meet for thee. 
Being strong, strive ever upward like a fire ; 

Still aspire 
Toward the Perfect and the Pure — 
God appoints thy life, be sure. 

Never tire. 
Trust that all things well-ordered from above 

Piightly move. 
God is just — hold fast that creed. 
It will serve thee in thy need, 
Till tiiou come to know indeed 

God is love, " 



$tt fHcmortam. 



But to return — when the writer of this brief memoir 
entered the wards of the Meath Hospital and Counts- 
Dublin Infirmary as a medical student in the winter 
session of the year 1866, he found John Todhunter acting 
as Clinical Clerk to two great physicians, William Stokes 
and Alfred Hudson — men who were the complement of 
each other, Stokes, the i)hilosophic physician ; Hudson, 
the keen observer and the skilled and resourceful thera- 
peutist. 

ToDHUNTER took the neophyte by the hand, initiated 
him into the mysteries of bedside teaching and learning, 
taught him the rudiments of clinical medicine, by his 
conduct and example brought home tc his mind the 
solemnity of the work in which teacher and taught 
were engaged, and showed him in a practical way how 
precious a privilege it is to minister to the sick and suffer- 
ing. Small wonder, therefore, that the writer remembers 
those far-off days with gratitude and pleasure. 



•J. W. M. 



INDEX 



TO THE 



ONE HUNDRED AND FORTY-SECOND VOLUME 



AiiJesthesia, surgical, a manual of, H. B. 

Gardner, lia:. 40. 
Anatomj^ descriptive and applied. H. 

Gray, edited by Prof. Howden, 

Rev., 317, 
Appendicitis, acute, with i^eritonitis 

J. W. Long on, 148. 



Back injuries and their significance 

under the W'orkmen's Compensation 

and other Acts, A. M'Kendrick, 

Rev.. 339. 
Bacteriology, aids to, C. G. IMoor and 

Wm. Partridge. Rev., 172. 
Bandaging, a practical maniial of. I). C 

Pitz^Villiams, Rev., 403. 
Barlow, F. C, translator of notes on the 

technique of effective bromide 

therapy in epilepsy, by Dr. A. Ulrich, 

Rev., 55. 
Basic anatomical nomenclature, E. B. 

Jamieson, Rev.. 403. 
Bernliardi and creation. Sir J. Crichton- 

Browne. Rcr.. 53. 
Berry, J., and F. M. D., the story of a 

red cross unit in Serbia. Rev., 311. 
Binnie, J. F., manual of operative 

surgery, Rev., 246. 
Biographical notices, an index to the — ■ 

that have appeared in the Journal 

since its commencement in March 

1832, T. P. C. Kirkpatrick on, 110. 
Biological Society of the Royal College 

of Surgeons in Ireland, 411. 
Blood-pressure, studies in, G. Oliver, 

Rev., 402. 
Bonney, V., editor of Archives of the 

Middlesex Hospital, No. XV., Rev., 

52. 
Bosanquet, W. C, scrums, vaccines and 

toxins in treatment and diagnosis. 

Rev., 331. 
Bruce, A., editor of Influence of Joy, 

by Van Ness Dearborn, Rev., 320. 



Brunton, Sir Lauder, preface to modem 
medicine and some modem remedies, 
by T. B. Scott, Rev., 48. 

Bullet injuries of nerves and other 
treatment, Mr. Haughton on, 60. 



Cancer, mortality from, throughout the 

world, W. L. Hoffman. Rev., 51. 
Cancer, notes on the causation of. Hon. 

R. Russell, Rev., 405. 
Cardiac curves and sounds, G. A, 

Stephens on. 221. 
Carruthers, T., urine examination made 

easy. Rev.. 182. 
Charlotte Medical Journal, Vol. 73, 

No. 2, February. 1916, 327. 
Child mentally defective, M. Young. 

Rev., 176. 
Child, the, welfa.e annual, edited by 

T. N. Kelynack, Vol. I.. Rev., 180. " 
Children, diseases of, D. Fordycc, Rev., 

406. 
Consumptives, Massachusetts Hospital 

for, ninth annual report of the 

trustees of, Nov. 30, 1915, Rev., 318. 
Cosgrave, MacDovvel. on Drumcondra 

Hospital, a short history, 386. 
Crichton-Browne, Sir J., Bernhardi and 

creation. Rev., 53. 
Cullen, T. S.. embryology, anatomy and 

diseases of the umbilicus. Rev., 187. 



Dearborn, G. Van Ness, inlluence of joy, 

Rev., 320. 
Deleterious liquids or substances, 259. 
Dermatology, an introduction to, N- 

Walker, Rev., 321. 
Diabetes and acidosis, acute, 142. 
Diabetes, remarks on the Allen treal- 

ment of, G. Nesbitt on, 379. 
Diabetes, the Allen treatment of, Dr. 

Nesbitt on, 417. 

2i 



442 



Index. 



Dictionary, the practitioner's medical, 

G. M. Gould, revised and eidarged bv 

E. J. E. Scott. Rev.. 124. 
Dog as a carrier of disease, 237. 
Drumcondra Hospital, a short history, 

MacDowel Cosgravc on, 386. 
Drummond. AV. B., phj'siology for 

nurses, Rev., 45. 
Drury, Dr. H.. presidential address by. 

370. 
Dublin charity and the late rebellion. 

262. 
Dublin during the rebellion. 55. 
Dublin University Calendar for the year 

1916-1917. 



Eclipse or Empire? H. B. Gray and S. 

Turner, Rev., 401. 
Embryology, anatomy and diseases of 

the umbilicus, together with diseases 

of the urachus, T. S. Cullen, Rev., 187. 
Epilepsy, notes on the technique of 

effective bromide therapy in. Dr. 

A. Uirich, translated by F. C Barlow, 

Rev., 55. 
Epistaxis. recurrent, treated by fresh 

bone marrow, 62. 
Evans, A., nerve injuries and their 

treatment, Rev., 174. 
Eyre, J. \V. H., scrums, vaccines and 

toxines in treatment and diagnosis, 

Rev., 331. 



Faulkner, R. B., recent works on 

tonsils, Rev., 185. 
Fitzgerald, C. E., "In Memoriam, 69." 
FitzWilliams, D. C., a practical manual 

of bandaging, Rev., 403. 
Fleas as a menace to man and domestic 

animals, J. Watorston, Rev., 343. 
Fordyce, D., diseases of children, Rev., 

406. 
Fractures and fracture dislocations, 

J. S. M'Ardle on, 74, 145, 289. 



Galyl, 36. 

Gardner, H. 1}., a manual of surgical 

ansesthcsia. Rev., 40. 
Giles, A. E., the diseases of women. 

Rev., 123. 
Gould, G. M., the practitioner's medical 

dictionary. Rev., 124. 
Graves, Wm. P., gynajcology. Rev., 175. 
Gray, H., anatomy, descriptive and 

applied, edited by Prof. 11. llowden, 

Rev., 317. 



Gray, H. B.. eclipse or Empire, Rev., 
401. 

Gynecological Society, American, Trans- 
actions of the. Vol. XL., for the 
year 1915. Rev.. 323. 

Gynaecology, Wm. P. Graves, Rev., 175. 



Handbook for wives and mothers in 

India. M. Staley, Rev., 185. 
Handley. "\V. S., editor of Archives of 

the Middlesex Hospital, No. XV., 

Rev., 52: 
Heart affections, principles of diagnosis 

and treatment in, Sir James 

Mackenzie, Rev., 238. 
Heliotherapy in tuberculosis of the 

bones anct joints, E. M. Hewitt on, 

295. 
Hewitt, E. M.. on heliotherapy in 

tuberculosis of the bones and joints, 

295. 
Histology, descriptive and practical, 

the essentials of. Sir E. Schafer, 

Rev., 181. 
Historv of Medicine, an index to papers 

on, T. P. C. Kirkpatriek on, 302. 
Hoffman, F. L., the mortality of cancer 

throughout the world. Rev., 51. 
Howden, Prof., editor of anatomj', 

descriptive and applied, by H. Grajr, 

Rev., 317. 



In arduis fidelis, 68. 

In Memoriam — C. E. Fitzgerald. 69 ; 

R. L. Swan, 430; John Todhunter, 

438. 
Indian Medical Service. 344, 351. 
Inoperable uterine carcinoma, the 

technic of applying heat in treatment 

of, 194. 
Interstate Medical Joiirnal, Vol. 

XXIII., Rev., 407. 
Irish memorial to Edith C'avill, 262. 



Jamieson, E. B., the Basle anatomical 
nomenclature. Rev., 403. 

Jaundice, notes on camp, T. G. Moor- 
head and G. D. Harding, 1. 

Jov, influence of, G.^'an Ness Dearborn, 
edited by H. A. Bruce, Rev., 320. 



Kelynack, T. N.. editor of the Child 
Welfare Annual, Vol. I., Rev., 180. 

"Kepler" cod liver oil with malt 
extract and creosote, 419. 



indext 



443 



Kerr, J. M. 31.. operative midwifery'. 
Rev., 37. 

Kettle, E. H., the pathology of tumours. 
Rev.. 1S3. 

Kink, ileal. U4. . 

Kirkpatrick, T. P. C, an index to the 
biographical notices that have ap- 
peared in the Journa' since its 
eommencernent in IMari-h, 1832. 110 ; 
an index to papers on History of 
Medicine, 302. 



Laboratorj'^ nianual in genera^ n;iero- 
biology. Rev.. 177. 

Letter to the Editor, 210. 

Literarj^ intelligence, 68. 

Literary Notes, 288. 360. 

Longridge, C. J. N-. rcvisor of aids to 
obstetrics, by S. Nail, Rev., 122. 

Long. J. W., on acute appendicitis with 
peritonitis, 148. 

L'Ospedale maggiore. rivista mansile, 
illustrata, Ano TV., No. 2, Rev., 333. 

Lumsden, J., on the problem of tuber- 
cular soldiers discharged froni, the 
arm v. 190. 



M'Ardle, J. S., on fractures and fracture 

dislocations, 73, 145, 289. 
IM'Kendriek, A., back injuries and their 

significance under the Workmen's 

Compensation and other Acts, Rev., 

339. 
Mackenzie, J., principles of diagnosis 

and treatment in heart affections. 

Rev., 238. 
Manchester Babies' Hospital Medical 

Registrar's Report.. Aug. 1915 to 

July 1916. Rev., 409. 
Maternity Hospital, Clapham, twenty- 
seventh report of, 126. 
Maxwell. Dr. E., on, diagnosis in uveitis 

94, 158. 
Medical clinics of Chicago, Rer., 410. 
Medical Education and Examinations 

in Ireland, 1916-1917, 263. 
Medical examinations of recruits in the 

British Army and Continental Armies, 

the visual standards used, J. V. 

Patterson and H. M. Tracj^uair, Rev., 

189. 
Medical Journal, Charlotte, Vol. 72, 

No. 6, Rev., 46. 
Medicine, modern, and some modern 

remedies, T. B. Scott : preface by 

yir L. Brunt on. Rev., 48, 



Medicine and chirurgery, carh' works 

on the sciences of, 332. 
Medicine of Colombia, bulletin of. 

Vol. I„ Nos. 1 and 2, Rev., 42. 
Micro-biometrics, some suggestions in, 

E. Wooton on. 227. 
Middlesex Hospital, archives of. No. 

XV., edited by W. S. Handley and 

V. Bonney, Rev., 52. 
Midwifery, operative, J. il. Munro 

Kerr, Rev., 37. 
Miles, A., manual of sxirgery. Rev., 246. 
Moorhead, T. G., notes on camp 

jaimdice, 1 ; address, 411. 
Moore. Sii- John, meteorological notes, 

63, 200, 204, 249, 253, 352, 356, 360. 
Moor, aids to bacteriology, Rev., 172. 



Nail, S., aids to obstetrics. Rev., 122. 

National University of Ireland, calendar 
for the year 1916, Rev., 341. 

Nerve injuries and their treatment, 
P. Stewart and A. Evans, Rev., 174. 

Nervous diseases, diagno.sis of, P. 
Stewart, Rev., 119. 

Nesbitt, G., remarks on the AUen 
treatment of diabetes, 379, 417. 

New preparations and scientific inven- 
tions, 418. 

Nurses, physiology for, W. B. Drum- 
mond, Rev., 45. 



Obstetrics, aids to. S. Nail, Rev., 122' 
revised by C. J. N. Longridge. 

Ohver, G., studies in blood -pressure, 
Rev., 402. 

Optochin hydrochloride, 260. 



Partridge, Wm-. aids to bacteriology, 
Rev., 172. 

Pathological lying, accusation and 
is-fvindling, W. Healy, Rev., 49. 

Pathology, modern, a pioneer of, 
Death of Professor Metchnikofi, 127, 

Pattereon, J. V.. the visual standards 
used in medical examination of 
recruits in British Ani;y and Con- 
tinental Armies, Rev., 189. 

Peripheral nerves, injuries to, remarks 
on, by Major Purser, 59. 

Periscope. 36. 58, 67. 68, 131, 142, 144, 
171, 194, 237. 259, 288. 344. 351. 

Picardy, the great offensive, 1 95. 

Porro's operation, 1 71 - 



444 



Index. 



Port-mortem examinations, W. S. 

Wadsworth, Err., 324. 
Power, T. D., on the prophylaxis of 

venereal disease, 213. 
Presidential address. Dr. H. Dniry on, 

370. 
Pritchard, Dr. E., on rickets, 400. 
Prize of 50,000 francs for best nxechani- 

cal hand ajjparatus. 261. 
Purefoy. R. D.. on clinical report of 

Rotunda Hospital for one year, Nov. 

1st, 1914. to Oct. 31st, 191.5, 21, GO, 

79. 
Purser, Major F. C, remarks to 

injuries to peripheral nerves, 59. 



Red Cross imit in Serbia, the story of 

a, J. Berry and JM. D. Berry. Rfv., 

311. 
Report by the Director- General of 

Public Health, New South Wales, for 

1914. Rev., 404. 
Rickets, Dr. E. Pritc^iard on, 400. 
Rotunda Hospital clinical report of, for 

one year, Nov. 1st. 1914. to Oct. 31st, 

191.5. SirWm. Smyiy, R. Purefoy and 

E. H. Tweedy on. 21, HO. 79. 
Royal Academy of Medicine in Ireland. 

55, 417. 
Royal College of Phvsicians of Ireland 

58, 350. 
Royal College of Surgeons in Ireland. 

131. 
Royal Medical Benevolent Fund. 210. 



Sanitary and meteorological notes, Sir 
John Moore on, 03. 132, 1.36, 200, 
204, 249, 253, 352, 356, 360, 420, 429. 

Schiifer, Sir E., the essentials of his- 
tology, descriptive and practical, for 
the use f)f students, Rev., 181. 

Scott, It. .J. E., levisor of the practi- 
tioner's medical dictionary, Rev., 124. 

Scott, T. B., modern medicine and some 
modern remedies, Rev., 48. 

Senile decay, the metabolism of, E. 
Wooton on, 9. 

Serums, vaccines and toxins in treat- 
ment and diagnosis, W. C. Bosanquet 
and .1. H. Eyre, Rev., 331. 

Smithies, F., cancer of the' stomach, 
Rev., 246. 

Smyly, Sir Wm., clinical report of 
the Rotunda Hospital for one vear. 
Nov. 1st, 1916, to Oct. 31st, 1915, 
21. (10, 79. 



Staley, M., handbook for wives and 
mothers in India, Rev., 185. 

Stephens, G. A., cardiac curves and 
sounds, Rev., 221. 

Stewart, P., nerve injuries and their 
treatment. Rev., 174 ; the diagnosis 
of nervoiis diseases. Rev., 119. 

Stomach, cancer of the, F. Smithies, 
Rev., 246. 

Surgery, manual of, A. Thomson, Rev., 
246. 

Surgery, operative, manual of, J. Fair- 
bairn, Rev., 246. 

Surgery, experiences of renal, by Lt.- 
Col. W. Taylor, 361. 

Surgical pathological physiology, notes 
on. Vol. I., Rev., 406. 

Sutton, Sir J. B.. the diseases of women. 
Rev., 123. 

Swan, R. L., " In Memoriam," 430. 

Swanzv, Sir Henry, memorial to the 
late,' 348, 



Taylor, Lt.-Col. W., experiences of 
renal surgerj', 361. 

Thomson, A., manual of surgery, Rev., 
246. 

Tonsils, recent works on, R. B. 
Faulkner, Rev., 185. 

Traquair, H. M., the visual standards 
used in the medical examination of 
recruits in the British Army and 
Continental Armies, Rev., 189. 

Tramnatic pneumonia and traumatic 
tuberculosis, F. P. Weber, Rev., 328. 

Tubercular soldiers discharged from the 
army. Dr. J. Lumsden on the pro- 
blem of, 190. 

Tinnours, the pathologv of. E. H. 
Kettle, Rev.. 183. 

Turner, S., Eclii)se or Empire ? Rev., 

Tweedy, T. H.. on clinical report of the 
Rotunda Hospital for one year, 
Nov. 1st, 1914, to Oct, 31st, 1915, 
12, 60, 79. 



Ulrich, Dr. A., notes on the technique 
of effective bromide therapy in 
epilpsey, translated by F. ('. Barlow, 
Rev., 54. 

Urine examination made easy, T. 
(larruthers, 182. 

Uveitis, diagnosis in, E. Maxwell on, 
94, j.58, 



Index, 



445 



Venereal disease, report on, Bttv., 329. 
Venereal di^'ease, the prophylaxis of, 
T. B. Power on, 213. 



Wadsworth.W. S., 2'>o-^l-'>norle,m examina- 
tions, Rev., 324. 

Walker, N., an introduction to derma- 
tology. Rev., 321. 

War time economy, a medical grievance, 
348. 

Waterston, J., fleas as a menace to 
man and domestic animals, Rev., 343. 

Weber, F. P., traumatic pneumonia and 
traumatic tuberculosis, Rrv., 328. 



Weir Mitchell memorial, address and 

resolutions, Rev., 33(5. 
Women, the diseases of. Sir J. B. 

Sutton and A. E. Giles, Rev., 123. 
Wooton, Ed., on the metabolism of 

senile decay, 9 ; on some suggestions 

in micro-biometries, 227. 



Yellow fever, the intermediate host of, 

261. 
Young, M., the mentally defective 

child, Rev., 176. 



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